Methods and compositions for treatment of disorders ameliorated by muscarinic receptor activation

ABSTRACT

Methods for the treatment of CNS disorders using combinations of muscarinic activators and inhibitors, and medicaments comprising muscarinic activators and inhibitors.

FIELD OF INVENTION

The present invention relates to: (1) a method of using a combination of one or more muscarinic agonists and one or more muscarinic antagonists for treatment of diseases that are ameliorated by activation of muscarinic receptors (e.g., schizophrenia and related disorders); and (2) a medicament comprising one or more muscarinic agonists and one or more muscarinic antagonists.

BACKGROUND OF THE INVENTION

The acetylcholine neurotransmitter system plays a significant role in a variety of central nervous system (CNS) and peripheral functions. Acetylcholine signaling occurs through two different families of receptors: nicotinic receptors and muscarinic receptors. Muscarinic cholinergic receptors are G-protein coupled receptors with five different receptor subtypes (M1-M5) (Raedler et al. American Journal of Psychiatry. 160: 118. 2003), each of which are found in the CNS but have different tissue distributions. Activation of the muscarinic system through use of muscarinic agonists has been suggested to have the potential to treat several diseases including Alzheimer's disease, Parkinson's disease, movement disorders and drug addiction. (US 2005/0085463; Langmead et al. Pharmacology & Experimental Therapeutics. 117: 232:2008). Genetic evidence has suggested a direct link between the muscarinic system and both alcohol addiction (Luo X. Et al. Hum Mol Genet. 14:2421. 2005) and nicotine addiction (Mobascher A et al. Am J Med Genet B Neuropsychiatr Genet. 5:684. 2010). M1 and M4 subtypes have been of particular interest as therapeutic targets for various diseases. For instance, the mood stabilizers lithium and valproic acid, which are used to treat bipolar depression, may exert their effects via the muscarinic system particularly through the M4 subtype receptor. (Bymaster & Felder. Mol Psychiatry. 7 Suppl 1:S57. 2002).

Some of the strongest linkages to the muscarinic system have been with schizophrenia, which is a serious mental illness affecting approximately 0.5-1% of the population. (Arehart-Treichel. Psych News. 40:9. 2005). The disease is characterized by a set of symptoms that are generally divided into three categories: 1) Positive symptoms (e.g., hallucinations, delusional thoughts, etc.); 2) Negative symptoms (e.g., social isolation, anhedonia, etc.); and 3) Cognitive symptoms (e.g., inability to process information, poor working memory, etc.). (Schultz. Am Fam Physician. 75:1821. 2007). Patients who suffer from schizophrenia both experience a major decline in quality of life and are at increased risk for mortality due to a number of factors, such as an increased suicide rate. (Brown et al. British Journal of Psychiatry. 177: 212. 2000). The cost of schizophrenia to society is also significant as sufferers of schizophrenia are much more likely to be incarcerated, homeless or unemployed.

Today, antipsychotics are the mainstay of treatment for schizophrenia. The first generation of antipsychotics are generally known as “typical antipsychotics” while newer antipsychotics are generally called “atypical antipsychotics.” Both typical and atypical antipsychotics have limited efficacy and severe side effects. There is little to no difference in efficacy between typical and atypical antipsychotics, most likely due to the fact that both classes of drugs achieve their therapeutic effect through the same pharmacological mechanisms (e.g., acting as dopamine receptor antagonists). (Nikam et al. Curr Opin Investig Drugs. 9:37. 2008). Side effects of typical antipsychotics include abnormal movement (e.g., rigidity) whereas atypicals have different but equally significant side effects (e.g., major weight gain, cardiovascular effects, etc.). The side effect profile of current antipsychotics further decreases compliance in a patient population that is already frequently non-compliant. Thus, there exists a clear need for new therapeutics to treat schizophrenia and related disorders (e.g., schizoaffective disorder).

Clozapine is an example of an antipsychotic that has major side effects, including sialorrhea (hypersalivation) which occurs in up to 54% of patients. (Davydov and Botts, Ann Pharmacother. 34:662. 2000). The exact mechanism of hypersalivation remains unknown. (Rogers and Shramko. Pharmacotherapy. 20:109. 2000). Clozapine has a complex pharmacological profile with appreciable activity at a variety of receptors, including dopamine receptors, serotonin receptors, adrenergic receptors, muscarinic receptors and possibly others. (Coward. Br J Psychiatry Suppl. 17:5. 1992). Investigators have tried a variety of pharmacological approaches in an attempt to counteract sialorrhea, including botulinum toxin (Kahl et al. Nervenarzt. 76:205. 2005) as well as the antipsychotics amisulpride (Croissant et al. Pharmacopsychiatry. 38:38. 2005) and sulpiride. (Kreinin et al. Isr J Psychiatry Relat Sci. 42:61. 2005). Efforts have focused mostly on alpha2 adrenergic agonists as well as anti-cholinergic drugs due to clozapine's known interaction with these receptors. Anti-muscarinic drugs such as pirenzepine have shown efficacy in small scale trials (Schneider et al. Pharmacopsychiatry. 37:43. 2004), but other trials with the same agent found no effect. (Liu et at. J Clin Psychopharmacol. 21.:608. 2001). Alpha2 adrenergic agonist such as clonidine (Singh et al., J Psychopharmacol. 19:426. 2005) have also shown efficacy in reducing sialorrhea in small scale trials. However, Syed et al. reported in a 2008 review that there is inadequate data to guide clinical practice. (Syed et al. Cochrane Database Syst Rev. 16:3. 2008).

Another approach to the treatment of schizophrenia has been use of muscarinic agonists. Muscarinic receptors are G-protein linked receptors that bind the neurotransmitter acetylcholine. (Eglen R M. Auton Autacoid Pharmacol 26: 219. 2006). To date, five subtypes of muscarinic receptor have been identified and are generally labeled M1, M2, M3, M4, and M5, respectively. (Caulfield M P et al. Pharmacol. Rev. 50: 279. 1998). These muscarinic subtypes vary in terms of the affinity of various agonists and antagonists for the receptors. A number of lines of evidence have suggested that the muscarinic system plays a significant role in the pathology of schizophrenia. In particular, decreased expression of M1 and M4 receptor subtypes has been noted in post-mortem studies in deceased schizophrenic patients. (Dean et al. Mol Psych. 1: 54. 1996). Likewise, SPECT imaging studies have shown decreased muscarinic availability in schizophrenia. (Raedler et al. Am J Psych.160:118. 2003).

There is also pharmacological evidence implicating activation of muscarinic receptors as a potential therapeutic approach to schizophrenia. For example, the muscarinic antagonist scopolamine, which is used to treat motion sickness, produces cognitive impairment and delusions of the type seen in schizophrenia. (Ellis et al. Int. J. Neuropsychopharmacol. 9:175. 2006). More selective M1 agonists have been suggested to potentiate glutamate signaling which could help exert a therapeutic effect. (Jones et al. J. Neurosci. 28:10422. 2008). In a double-blind placebo controlled trial of schizophrenic patients using xanomeline, which has preferential activity at the M1 and M4 receptors, alleviation of schizophrenia was observed. (Shekhar et al. Am. J. Psych. 165: 1033. 2008). However, because xanomeline also bound to subtypes of receptors other than M1, a number of various serious side effects were observed including GI side effects, cardiac side effects and problems with hyper-salivation.

During the development of xanomeline, dose-limited adverse events were problematic and led to very high discontinuation rates (including a 56% dropout rate in a 26-week study of Alzheimer's disease) and eventually to discontinuation of xanomeline development. Despite the earlier promise of targeting muscarinic acetylcholine receptors for the treatment of CNS disorders as demonstrated in part by the clinical efficacy signal observed with xanomeline, no active pharmaceutical industry development for xanomeline has occurred for more than 15 years due to adverse events observed in previous studies. Many companies have attempted to develop muscarinic acetylcholine agonists for CNS disorders as is reflected in the collection of muscarinic activators disclosed herein, but no such agonist has reached the market, due to problematic tolerability profiles. The focus of these past development efforts has been an attempt to use medicinal chemistry to develop a molecule that would be more tolerable, typically by attempting to gain selectivity for the M1 and M4 muscarinic receptors subtypes over the M2 and M3 subtypes. The M2 and M3 subtypes are believed to be the main cause of the problematic adverse events with muscarinic activators, although M1 and M4 may play a role as well.

There is a need in the art to improve the tolerability of xanomeline, which could permit the development of xanomeline as a potential first-in-class, novel-mechanism-of-action agent for the treatment of cognitive and psychotic symptoms across a number of disorders for which there is a significant medical need, including schizophrenia, Alzheimer's disease, and others. In schizophrenia, existing treatments rely upon activity at the dopamine and serotonin receptors, as was the case with the first antipsychotic, chlorpromazine, which was discovered in 1952. For more than 60 years, the same fundamental pharmacology has provided the standard of care in schizophrenia. Current antipsychotics only have efficacy for positive symptoms while leaving negative and cognitive symptoms untreated. The lack of novel treatments over the last 60 years demonstrates the difficulty in developing new medicine in schizophrenia. Alzheimer's disease is another therapeutic area in which it has proven extremely difficult to develop new therapies, with a reported success rate for molecules that enter clinical development being approved by regulatory agencies for use of only 0.4% (Cummings et al., Alzheimers Res. Ther. 2014 Jul. 3; 6(4):37). New treatments are desperately needed by patients in these areas, but development has proved extremely difficult despite substantial effort from scientist and drug developers around the world.

To date, no one has been able to harness the approach of employing muscarinic agonists because of the side effects associated with the agents' binding certain muscarinic receptor subtypes. A need exists for a method of using muscarinic agonists and for a medicament employing such muscarinic agonists that would allow for the therapeutic effects associated with activation of muscarinic receptors, but with fewer side effects.

SUMMARY OF THE INVENTION

In one embodiment, the present invention relates to a method of treating diseases or conditions ameliorated by activation of the muscarinic system by administering one or more muscarinic “Activators” (e.g., agonist, partial agonist, co-agonist, physiological agonist, potentiator, stimulator, allosteric potentiator, positive allosteric modulator or allosteric agonist) and one or more muscarinic “Inhibitors” (e.g., antagonist, partial antagonist, competitive antagonist, non-competitive antagonist, uncompetitive antagonist, silent antagonist, inverse agonist, reversible antagonist, physiological antagonist, irreversible antagonist, inhibitor, reversible inhibitor, irreversible inhibitor, negative allosteric modulator, or allosteric antagonist). In a preferred embodiment, such diseases include schizophrenia and related disorders. In a preferred embodiment, a single muscarinic Activator and a single muscarinic Inhibitor are used. In a preferred embodiment, the combination of the Activator and Inhibitor has a score (“Theta score”) above 230 as determined by in silico testing using a proprietary algorithm as described herein. In another embodiment, more than one muscarinic Activator and/or more than one muscarinic Inhibitor are used.

In another embodiment of the invention, the method of treatment can be applied to a mammal. In another embodiment, the mammal is a human being.

In one embodiment of the invention, the use of the Inhibitor alleviates the side effects associated with use of the Activator. In another embodiment, use of the Inhibitor allows for a higher maximum tolerated dose of the Activator.

In one embodiment, the muscarinic Activator may be taken sequentially with the Inhibitor. In another embodiment of the invention, the muscarinic Activator may be taken concurrently with the Inhibitor. In a preferred embodiment of the invention, the Activator and Inhibitor are formulated to be contained in the same dosage form or dosage vehicle. In another embodiment of the invention, the muscarinic Activator and Inhibitor are formulated to be in separate dosage forms or dosage vehicles. In one embodiment, the Activator and Inhibitor are formulated in an immediate release dosage form. In another embodiment, Activator and Inhibitor are formulated in a controlled release dosage form. In another embodiment, either the Activator or the Inhibitor is formulated in an immediate release dosage form, while the other is formulated in a controlled release dosage form.

In another embodiment of the invention, the muscarinic Activator and Inhibitor can be taken orally. The Activator and Inhibitor may be given orally in tablets, troches, liquids, drops, capsules, caplets and gel caps or other such formulations known to one skilled in the art. Other routes of administration can include but are not limited to: parenteral, topical, transdermal, ocular, rectal, sublingual, and vaginal.

In another embodiment of the invention, the muscarinic Activator and Inhibitor are administered either simultaneously or consecutively with other therapies for schizophrenia. In one embodiment of the invention, the muscarinic Activator and Inhibitor are used simultaneously or sequentially with psychotherapy. In another embodiment of the invention, the muscarinic Activator and Inhibitor are administered either simultaneously or consecutively with other pharmacological therapies. Pharmacological therapies could include but are not limited to: antipsychotics, anxiolytics, anti-depressants, sedatives, tranquilizers and other pharmacological interventions known to one skilled in the art.

A separate embodiment of the invention is a medicament comprising both a muscarinic Activator and a muscarinic Inhibitor. In a preferred embodiment, the combination of the Activator and Inhibitor have a theta score above 230 as determined by in silico testing using a proprietary algorithm as described herein.

In another embodiment of the invention, the medicament can be taken orally. The medicament may be given orally in tablets, troches, liquids, drops, capsules, caplets and gel caps or other such formulations known to one skilled in the art. Other routes of administration can include but are not limited to: parenteral, topical, transdermal, ocular, rectal, sublingual, and vaginal.

In another embodiment of the invention, the medicament can be administered in conjunction with other therapies. In one embodiment of the invention, the medicament is used simultaneously or sequentially with psychotherapy. In another embodiment of the invention, the medicament is administered either simultaneously or consecutively with other pharmacological therapy. Such pharmacological therapy could include but is not limited to: antipsychotics, anxiolytics, anti-depressants, sedatives, tranquilizers and other pharmacological interventions known to one skilled in the art.

These and other embodiments of the invention, and their features and characteristics, will be described in further detail in the description and claims that follow.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates the relationships among p-Scores, Subscores, and Theta Scores in accordance with the present invention.

FIG. 2 illustrates features of the Study Design of Example 7.

DETAILED DESCRIPTION OF THE INVENTION Definitions

For convenience, before further description of the present invention, certain terms employed in the specification, examples and appended claims are collected here. These definitions should be read in light of the remainder of the disclosure and understood as by a person of skill in the art. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as would be understood by a person of ordinary skill in the art.

The articles “a” and “an” are used herein to refer to one or to more than one (i.e. to at least one) of the grammatical object of the article. By way of example, “an element” means one element or more than one element.

The terms “comprise” and “comprising” are used in the inclusive, open sense, meaning that additional elements may be included.

The term “consisting” is used to limit the elements to those specified except for impurities ordinarily associated therewith.

The term “consisting essentially of” is used to limit the elements to those specified and those that do not materially affect the basic and novel characteristics of the material or steps.

As used herein, unless otherwise specified, the term “controlled release” is defined as a prolonged release pattern of one or more drugs, such that the drugs are released over a period of time. A controlled release formation is a formulation with release kinetics that result in measurable serum levels of the drug over a period of time longer than what would be possible following intravenous injection or following administration of an immediate release oral dosage form. Controlled release, slow release, sustained release, extended release, prolonged release, and delayed release have the same definitions for the present invention.

The term “including” is used herein to mean “including but not limited to.” “Including” and “including but not limited to” are used interchangeably.

The term “mammal” is known in the art, and exemplary mammals include humans, primates, bovines, porcines, canines, felines, and rodents (e.g., mice and rats).

The terms “parenteral administration” and “administered parenterally” are art-recognized and refer to modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intra-articular, subcapsular, subarachnoid, intraspinal, and intrasternal injection and infusion.

A “patient,” “subject” or “host” to be treated by the subject method may mean either a human or non-human mammal.

The term “pharmaceutically-acceptable carrier” is art-recognized and refers to a pharmaceutically-acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, solvent or encapsulating material, involved in carrying or transporting any subject composition or component thereof from one organ, or portion of the body, to another organ, or portion of the body. Each carrier must be “acceptable” in the sense of being compatible with the subject composition and its components and not injurious to the patient. Some examples of materials that may serve as pharmaceutically acceptable carriers include: sugars, such as lactose, glucose and sucrose; starches, such as corn starch and potato starch; cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; powdered tragacanth; malt; gelatin; talc; excipients, such as cocoa butter and suppository waxes; oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil; glycols, such as propylene glycol; polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; esters, such as ethyl oleate and ethyl laurate; agar; buffering agents, such as magnesium hydroxide and aluminum hydroxide; alginic acid; pyrogen-free water; isotonic saline; Ringer's solution; ethyl alcohol; phosphate buffer solutions; and other non-toxic compatible substances employed in pharmaceutical formulations.

The term “pharmaceutically-acceptable salts,” used interchangeably with “salts,” is art-recognized and refers to salts prepared from relatively non-toxic acids or bases including inorganic acids and bases and organic acids and bases, including, for example, those contained in compositions of the present invention. Suitable non-toxic acids include inorganic and organic acids such as acetic, benzenesulfonic, benzoic, camphorsulfonic, citric, ethenesulfonic, fumaric, gluconic, glutamic, hydrobromic, hydrochloric, isethionic, lactic, maleic, malic, mandelic, methanesulfonic, mucic, nitric, pamoic, pantothenic, phosphoric, succinic, sulfuric, tartaric acid, p-toluenesulfonic, hydrochloric, hydrobromic, phosphoric, and sulfuric acids and the like.

The term “treating” is art-recognized and refers to curing as well as ameliorating at least one symptom of any condition or disorder.

The term “therapeutic agent” is art-recognized and refers to any chemical moiety that is a biologically, physiologically, or pharmacologically active substance that acts locally or systemically in a subject. Examples of therapeutic agents, also referred to as “drugs,” are described in well-known literature references such as the Merck Index (14^(th) edition), the Physicians' Desk Reference (64^(th) edition), and The Pharmacological Basis of Therapeutics (12^(th) edition) , and they include, without limitation, medicaments; vitamins; mineral supplements; substances used for the treatment, prevention, diagnosis, cure or mitigation of a disease or illness; substances that affect the structure or function of the body, or pro-drugs, which become biologically active or more active after they have been placed in a physiological environment.

The term “psychotherapy” refers to use of non-pharmacological therapies in which those skilled in the art use a variety of techniques that involve verbal and other interactions with a patient to affect a positive therapeutic outcome. Such techniques include, but are not limited to, behavior therapy, cognitive therapy, psychodynamic therapy, psychoanalytic therapy, group therapy, family counseling, art therapy, music therapy, vocational therapy, humanistic therapy, existential therapy, transpersonal therapy, client-centered therapy (also called person-centered therapy), Gestalt therapy, biofeedback therapy, rational emotive behavioral therapy, reality therapy, response based therapy, Sandplay therapy, status dynamics therapy, hypnosis and validation therapy. It is further understood that psychotherapy may involve combining two or more techniques and that a therapist can select and adjust the techniques based on the needs of the individual patient and the patient's response.

The term “Muscarinic Disorder” refers to any disease or condition that is ameliorated by activation of the muscarinic system. Such diseases include ones in which direct activation of muscarinic receptors themselves or inhibition of cholinesterase enzymes has produced a therapeutic effect.

The terms “Diseases Related To Schizophrenia” and “Disorders Related To Schizophrenia” include, but are not limited to, schizo-affective disorder, psychosis, delusional disorders, psychosis associated with Alzheimer's disease, psychosis associated with Parkinson's disease, psychotic depression, bipolar disorder, bipolar with psychosis, Huntington's disease, Lewy Body dementia, or any other disease with psychotic features.

The term “Movement Disorders” includes, but is not limited to, Gilles de la Tourette's syndrome, Friederich's ataxia, Huntington's chorea, restless leg syndrome and other diseases or disorders whose symptoms include excessive movements, ticks and spasms.

The term “Mood Disorders” includes major depressive disorder, dysthymia, recurrent brief depression, minor depression disorder, bipolar disorder, mania and anxiety.

The term “Cognitive Disorders” refers to diseases or disorders that are marked by cognitive deficit (e.g., having abnormal working memory, problem solving abilities, etc.). Diseases include but are not limited to Alzheimer's disease, Parkinson's Disease, dementia (including, but not limited to, AIDS related dementia, vascular dementia, age-related dementia, dementia associated with Lewy bodies and idiopathic dementia), Pick's disease, confusion, cognitive deficit associated with fatigue, learning disorders, traumatic brain injury, autism, age-related cognitive decline, and Cushing's Disease, a cognitive impairment associated with auto-immune diseases.

The term “Attention Disorders” refers to diseases or conditions that are marked by having an abnormal or decreased attention span. Diseases include but are not limited to attention hyperactivity deficit disorder, attention deficit disorder, Dubowitz Syndrome, FG Syndrome, Down's Syndrome, growth delay due to insulin-like growth factor I deficiency, hepatic encephalopathy syndrome, and Strauss Syndrome.

The term “Addictive Disorders” refers to diseases or conditions marked by addiction or substance dependence as defined by the Diagnostic & Statistical Manual IV. Such disorders are characterized by physical dependence, withdrawal and tolerance to a particular substance. Such substances include but are not limited to alcohol, cocaine, amphetamines, opioids, benzodiazepines, inhalants, nicotine, barbiturates, cocaine and cannabis. Addictive Disorders can also encompass behaviors that a patient does in a compulsive, continual manner despite clear negative consequences. For instance, ludomania is recognized by those skilled in the art as being an addictive behavior that often has devastating consequences.

The term “Activator” means a molecule that can be described as an agonist, partial agonist, co-agonist, physiological agonist, potentiator, stimulator, allosteric potentiator, positive allosteric modulator, allosteric agonist or a molecule that increases the activity or signaling of muscarinic receptors through direct or indirect means.

The term “Inhibitor” means a molecule that can be described as an antagonist, partial antagonist, competitive antagonist, non-competitive antagonist, uncompetitive antagonist, silent antagonist, inverse agonist, reversible antagonist, physiological antagonist, irreversible antagonist, inhibitor, reversible inhibitor, irreversible inhibitor, negative allosteric modulator, allosteric antagonist or a molecule that decreases the activity or signaling of muscarinic receptors through direct or indirect means.

The term “maximum tolerated dose” means the highest dose of a drug or therapeutic that can be taken by patients without the patients' experiencing intolerable side effects. The maximum tolerated dose is typically determined empirically in clinical trials.

The term “Muscarinic receptors” refers to G-protein linked receptors that bind the neurotransmitter acetylcholine, and to date, five subtypes of muscarinic receptor have been identified. “M1” means the subtype one muscarinic receptor. “M2” means the subtype two muscarinic receptor. “M3” means the subtype three muscarinic receptor. “M4” means the subtype four muscarinic receptor. “M5” means the subtype five muscarinic receptor.

The term “Antipsychotic” refers to a drug that diminishes psychosis, hallucinations or delusions. Antipsychotics can include, but are not limited to: Haloperidol, droperidol, chlorpromazine, fluphenazine, perphenazine, prochlorperazine, thioridazine, trifluoperazine, mesoridazine, periciazine, promazine, triflupromazine, levomepromazine, promethazine, pimozide, chlorprothixene, flupenthixol, thiothixene, zuclopenthixol, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, amisulpride, asenapine, paliperidone, zotepine, aripiprazole, bifeprunox, and tetrabenazine .

The term “Anxiolytics” refers to drugs that reduce anxiety, fear, panic or related feelings. Such drugs include, but are not limited to: benzodiazepines (e.g., alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, lorazepam), buspirone, barbiturates (e.g., amobarbital, pentobarbital, secobarbital, phenobarbitol) and hydroxyzine.

The term “Anti-depressants” refers to drugs that alleviate depression and related conditions (e.g., dysthymia) and include, but are not limited to: Selective serotonin-reuptake inhibitors (e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline), serotonin- norepinephrine reuptake inhibitors (e.g., desvenlafaxine, duloxetine, milnacipram, venlafaxine), mianserin, mirtazapin, norepinephrine reuptake inhibitors (e.g., atomoxetine, mazindol, reboxetine, viloxazine), bupropion, tianeptine, agomelatine, trycyclic antidepressants (e.g., amitriptyline, clomipramine, doxepin, imipramine, trimipramine, desipramine, nortriptyline, protriptyline), monoamine oxidase inhibitors (e.g., isocarboxazid, moclobemide, phenelzine, selegiline, tranylcypromine).

The terms “Sedatives” or “tranquilizers” refer to drugs that induce somnolence, promote a feeling of being tired or desire to sleep or promote a state of unconsciousness. Such drugs include but are not limited to benzodiazepines, barbiturates (e.g., amobarbital, pentobarbital, secobarbital, phenobarbitol), eszopiclone, zaleplon, zolpidem, zopiclone.

The term “Theta Score” is defined as the numerical value assigned by an in silico algorithm described herein used to predict the overall efficacy and side effects of any given combination of a Muscarinic Activator and a Muscarinic Inhibitor.

Introduction

The present invention relates to the method of use of one or more Activators and Inhibitors of muscarinic receptors in combination for treatment of various disorders that can be ameliorated by activation of the muscarinic system. The present invention also describes a medicament comprising one or more Activators and one or more Inhibitors of muscarinic receptors. Use of muscarinic Activators has previously been hypothesized to be useful for various central nervous system related conditions. In particular, activation of the M1 and M4 receptor subtypes could prove to be of therapeutic value. However, no one has been able to advance M1 and M4 muscarinic Activators through clinical development to receive regulatory approval for CNS indications because of unacceptable side effects. For instance, while Activators of M1 and M4 muscarinic receptors have been suggested to be efficacious treatments for schizophrenia (Shekhar et al. Am J Psychiatry. 165:1033. 2008; Shirey et el. Nature Chem Biol. 4:41. 2007), the binding by those Activators to subtypes of muscarinic receptors besides M1 and M4 results in side effects which have prevented use of muscarinic Activators in the clinic. (Shekhar et al. Am. J. Psych. 165: 1033.2008). For instance, in both phase I and subsequent trials, the muscarinic agonist xanomeline had unacceptable GI side effects as well as other side effects primarily linked to binding of muscarinic receptors besides M1 and M4. (Sramek et al. The Journal of Clinical Pharmacology. 35:800. 1995), (Cutler & Sramek. Eur. J. Clin. Pharmacol. 48:421-428. 1995), (Bodick et al. Arch Neuro 54:465-473. 1997). By combining a muscarinic Activator with an Inhibitor, it is possible to achieve the desired therapeutic effect while diminishing or eliminating the side effects associated with unwanted subtype binding.

Muscarinic Inhibitors are used for treatment of overactive bladder and pulmonary disorders and have been suggested for treatment of other disorders. (Witte L P et al. Curr. Opin. Urol.1:13. 2009). Groups have outlined use of muscarinic Inhibitors with drugs in other classes to achieve a greater effect for treatment of a disease. For example, WO 2008/121268 suggests a combination for the treatment of lower urinary tract symptoms (LUTS) consisting of a beta-3 adrenergic agonist, which on its own has been investigated for the treatment of LUTS, and a muscarinic antagonist. Others have suggested combining specific muscarinic Activators or Inhibitors with other specific therapeutic agents other than muscarinic agents to further have a therapeutic effect (e.g., WO 2009/037503, WO 2009/036243, WO 2008/104776, WO 2008/096136, WO 2008/096126, WO 2008/096121, WO 2008/096111, WO 2007/127196, WO 2007/125293, EP 2002843, EP 2002844, U.S. Pat. No. 5,744,476, U.S. Pat. No. 7,524,965, US 2005/0267078, US 2006/0189651, and US 2008/0045565). US 2006/0287294 A1 outlines use of aspartyl protease inhibitors with either an M1 agonist or an M2 antagonist for treatment of various diseases, including improvement of cognitive deficit. Both M1 Activators and M2 Inhibitors themselves (Carey et al. Eur J Pharmacol 431:198. 2001.) have been suggested to be useful treatments for cognitive deficit, and the rationale for the combination with the aspartyl protease inhibitor was to enhance the effects of the aspartyl protease inhibitor. No suggestion was made of combining the M1 Activator with the M2 Inhibitor, and both compounds would be capable of reaching and would be active in the central nervous system. U.S. Pat. No. 5,480,651 discloses use of agents that increase acetylcholine in the synapse or that activate the nicotinic acetylcholine receptors, followed by administration of an acetylcholine receptor antagonist to relieve craving associated with nicotine addiction. The preferred composition uses physostigmine which is an inhibitor of acetylcholinesterase, as opposed to a muscarinic Activator which would not activate the nicotinic acetylcholine receptors. WO 03/092580 discloses compounds that can act simultaneously as muscarinic Activators at certain receptor subtypes and antagonists at others. Groups have used various muscarinic Activators with muscarinic Inhibitors in the context of trying to differentiate the role of various muscarinic subtypes in drug pharmacology or normal physiology without suggesting a therapeutic use of the combination. Such studies include use of cellular assays starting from animal materials. (e.g., Iwanaga K. et al. J. Pharmacol. Sci. 110:306. 2009). In US 2009/0318522, Paborji discloses use of a peripherally-acting muscarinic antagonist targeting the M2 and M3 receptors for the treatment of overactive bladder. The Paborji publication also discloses use of a peripherally-acting muscarinic M2/M3 agonist to counteract dry mouth associated with the peripherally-acting M2/M3 muscarinic antagonist. Paborji's approach does not, however, relate to activity at muscarinic receptors in the CNS, which is of critical importance for the work described herein, nor does it pertain to activity at either the M1 or M4 receptor. Paborji's approach is highly limited to a specific muscarinic inhibitor and does not provide any selection criteria to identify preferred or specific combinations of muscarinic Activators with the muscarinic antagonist, in spite of the prohibitively large number of potential combinations for which experimental testing could be done.

We have developed a novel approach to improve the tolerability of xanomeline, which is a muscarinic Activator, by co-administering trospium chloride, which is a muscarinic antagonist. Our approach is completely different from the medicinal chemistry approaches that have been the focus of efforts in the past to develop muscarinic agonist treatment with improved tolerability. Based on our in silico testing, we believe that xanomeline and trospium chloride is an optimal combination.

The most common adverse events observed with administration of xanomeline are nausea, vomiting, diarrhea, excessive sweating, and excessive salivation (so-called cholinergic adverse events) (Boddick et al., Arch Neurol. 1997 April; 54(4):465-73; Shekhar et al. Am. J. Psych. 165: 1033. 2008)). A demonstration of reduction in the incidence rate of these adverse events in humans would provide compelling evidence of improvement in the tolerability of xanomeline. We describe such a demonstration herein.

Method of Using Muscarinic Activators in Combination with Muscarinic Inhibitors

In one embodiment of the invention, one or more muscarinic Activators are used in combination with one or more Muscarinic Inhibitors for treatment of Muscarinic Disorders. In a preferred embodiment, such diseases or disorders include schizophrenia and Diseases Related to Schizophrenia. In another embodiment one or more muscarinic Activators are used in combination with one or more Muscarinic Inhibitors for treatment of Mood Disorders. In another embodiment, one or more muscarinic Activators are used with one or more muscarinic Inhibitors to treat Movement Disorders. In another embodiment, one or more muscarinic Activators are used with one or more muscarinic Inhibitors to treat Cognitive Disorders, including using the combination to enhance cognitive function not associated with a specific pathology. For instance, improvement in cognition could be important in undertaking complex tasks. In another embodiment, one or more muscarinic Activators are used with one or more muscarinic Inhibitors to treat Attention Disorders. Outside of disease treatment, enhancement of attention could improve learning and decrease symptoms associated with fatigue due to both lack of sleep and circadian rhythm disturbances such as jet lag. In another embodiment, one or more muscarinic Activators are used with one or more muscarinic Inhibitors to treat Addictive Disorders.

In another embodiment, the combination of one or more muscarinic Activators with one or more Muscarinic Inhibitors can be used to treat Muscarinic Disorders which are characterized by an amelioration of symptoms in response to inhibitors of cholinesterase enzymes. While cholinesterase inhibitors have proven therapeutic for certain diseases (e.g., Alzheimer's disease), the use of such inhibitors is limited due to toxicity. In fact, powerful chemical weapons such as sarin gas exert their toxic effects by inhibiting acetylcholinesterase (sarin gas material safety data sheet 103d Congress, 2d Session. United States Senate. May 25, 1994. http://www.gulfweb.org/bigdoc/report/appgb.html). The combination of one or more muscarinic Activators with one or more Muscarinic Inhibitors represents not only a safer method of treatment of those diseases shown to be response to cholinesterase inhibitors, but also a more effective one given the limitations on current cholinesterase inhibitors.

In one embodiment, the combination of one or more muscarinic Activators with one or more Muscarinic Inhibitors is used to treat an animal. In a further embodiment, the animal is a mammal. In a preferred embodiment, the mammal is a human being. In one embodiment, a single muscarinic Activator and a single muscarinic Inhibitor are used. In another embodiment more than one muscarinic Activator and/or more than one muscarinic Inhibitor is used.

In one embodiment, use of the Inhibitor decreases the side effects associated with use of the Activator. Such side effects include, but are not limited to, GI side effects, cardiac side effects, excessive sweating and excessive salivation. Use of one or more Inhibitors in combination with one or more Activators may allow the Activators to be used clinically when the Activators may not otherwise be used clinically due to the their side effects. In another embodiment, use of the Inhibitor in conjunction with the Activator allows for the Activator to achieve a higher maximum tolerated dose than the Activator would otherwise achieve.

Various time and resource intensive methods may be used to demonstrate both the efficacy of combination of the Activator and Inhibitor for the aforementioned embodiments. For example animal models have been used to demonstrate the efficacy of new therapeutics for schizophrenia, including both pharmacological models (e.g., ketamine model) and genetic models. (e.g., DISC1 mouse) (Dawe G S et al. Ann Acad Med Singapore. 38:425. 2009; Desbonnet L. Biochem Soc Trans. 37:308. 2009; Geyer M A. Neurotox Res. 14:71. 2008). Likewise, animal models including rodents, dogs and non-human primates can be used to demonstrate the side effect profile of pharmacological agents. Animal models serve as an experimental proxy for humans, but may suffer from deficiencies associated with the physiological differences between human and animals and thus may have limited predictive power for translation to human experiments, particularly for central nervous system disorders. Alternatively, the combination can be tried in controlled clinical trials of people. Standard measures based on patient self-report can be used by those skilled in the art to assess various side effects such as GI discomfort. As another example, objective physiological measures (e.g., EKGs) may be used by those skilled in the art. A set of standard measures has also been developed to assess schizophrenia symptoms including the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression (CGI). (Mortimer A M. Br J Psychiatry Suppl. 50:s7. 2007). Typically, clinical trials are conducted in a double blinded manner in which one group of patients receives an inactive placebo and the other group the active intervention.

In one embodiment of the invention, the muscarinic Activator is administered concurrently with the muscarinic Inhibitor. In another embodiment, the muscarinic Inhibitor is administered consecutively with the Activator. In further embodiment, the muscarinic Activator is administered prior to administration of the muscarinic Inhibitor. In another embodiment, the muscarinic Inhibitor is administered prior to administration of the muscarinic Activator. In one embodiment, the muscarinic Inhibitor is administered within one hour of administration of the muscarinic Activator. In another embodiment, the muscarinic Inhibitor is administered within 30 minutes of administration of the muscarinic Activator. In another embodiment, the muscarinic Inhibitor is administered within 10 minutes of administration of the muscarinic Activator. In another embodiment, the muscarinic Inhibitor is administered within one minute of administration of the muscarinic Activator. In another embodiment, the muscarinic Inhibitor is administered within 30 seconds of administration of the muscarinic Activator. Prior to the start of a drug regimen of the type outlined above, there may be a lead-in period that lasts from one to fourteen days. During this lead-in period, the muscarinic Inhibitor may be given by itself prior to the start of administration of the combination.

In one embodiment, from 10 micrograms to 10 grams of Activator is used in the combination with the Inhibitor. In another embodiment, from 1 milligram to 1 gram of Activator is used in the combination with the Inhibitor. In a preferred embodiment, from 5 to 500 milligrams of Activator is used. In one embodiment from 10 micrograms to 10 grams of Inhibitor is used in the combination with the Activator. In another embodiment, from 1 milligram to 1 gram of Inhibitor is used in the combination with the Activator. In a preferred embodiment, from 2.5 milligrams and 200 milligrams of Inhibitor is used.

In one embodiment, the muscarinic Activator and muscarinic Inhibitor are administered to a patient 6 times during a 24 hour period. In another embodiment, the muscarinic Activator and muscarinic Inhibitor are administered to a patient 5 times during a 24 hour period. In another embodiment, the muscarinic Activator and muscarinic Inhibitor are administered to a patient 4 times during a 24 hour period. In a preferred embodiment, the muscarinic Activator and muscarinic Inhibitor are administered to a patient 3 times during a 24 hour period. In another preferred embodiment, the muscarinic Activator and muscarinic Inhibitor are administered to a patient 2 times during a 24 hour period. In another preferred embodiment, the muscarinic Activator and muscarinic Inhibitor are administered to a patient one time during a 24 hour period.

In one embodiment, the muscarinic Inhibitor is administered for one or more dose periods prior to administration of the muscarinic Activator to allow for accumulation of the muscarinic Inhibitor in the body, or for the muscarinic Inhibitor to reach or approach steady state exposure levels. This accumulation, or higher exposure levels of the muscarinic Inhibitor, could increase the blockade of muscarinic receptors and reduce adverse events upon initiation of dosing of the muscarinic Activator. In another embodiment, the muscarinic Inhibitor is administered for one or more days prior to administration of the muscarinic Activator.

In one embodiment, xanomeline is administered as a muscarinic Activator in combination with trospium chloride as a muscarinic Inhibitor. In another embodiment, 225 mg of xanomeline as a muscarinic Activator and 40 mg of trospium chloride as a muscarinic Inhibitor are administered to a patient in a 24 hour period. In a further embodiment, 75 mg of xanomeline as a muscarinic Activator is administered three times a day, and 20 mg of trospium chloride as a muscarinic Inhibitor is administered twice a day, to a patient in a 24 hour period. In another embodiment, trospium chloride is administered for one or more dose periods prior to administration of xanomeline. In another embodiment, trospium chloride is administered for one or more days prior to administration of xanomeline.

In Silico Testing of Muscarinic Combinations

There are 65 unique muscarinic Activators and 114 unique muscarinic Inhibitors that are currently known (Adis R&D Insight™, Pubmed, Web of Science, U.S. FDA Orange Book, U.S. Pat. No. 5,852,029). Therefore, there exist 7,410 potential combinations in which a single muscarinic Activator could be paired with a single muscarinic Inhibitor. If one were to combine more than one muscarinic Activator with one or more muscarinic Inhibitors, then the number of combinations would be even greater. While a number of animal models exist for relevant diseases such as schizophrenia (Dawe G S et al. Ann Acad Med Singapore. 38:425. 2009; Desbonnet L. Biochem Soc Trans. 37:308. 2009; Geyer M A. Neurotox Res. 14:71. 2008), animal models of complex diseases such as schizophrenia are imperfect, and thus the ability to predict human efficacy and side effect burden based on animal data may be limited. Likewise, it is possible to test combinations in humans suffering from a particular disease such as schizophrenia where there exist standard measuring scales (Mortimer A M. Br J Psychiatry Suppl. 50:s7. 2007) for both efficacy of disease treatment as well as side effects. However, testing such a large number of combinations in either animal models of disease or more importantly in human clinical trials is practically impossible as it would be prohibitively expensive, and could take decades due to limitations in the number of existing skilled investigators and required time for patient recruitment.

Without a method of testing and predicting the efficacy of a given combination, it is extremely difficult to predict a priori if such a combination will be efficacious. For instance, Medina et al. gave the muscarinic agonist xanomeline and the muscarinic antagonist methscopolamine to investigate whether syncope, which is a side effect observed with xanomeline, can be mediated by muscarinic antagonists (Medina et al. Hypertension. 29: 828. 1997). The group observed no effect on syncope, which may reflect the lack of involvement of the muscarinic system in syncope or, alternatively, may reflect the incorrect selection of a muscarinic combination. Likewise, Maral et al. documented use of the muscarinic agonist RS-86 with the anticholinergic agent glycopyrrolate for treatment of Alzheimer's Disease (Maral et al. Neurology. 38:606. 1988). The approach did not result in any improvement in cognition despite use of escalating amounts of RS-86. US 2006/0194831 discloses use of a derivative of clozapine to activate muscarinic receptors. While US 2006/0194831 discloses that the use of the clozapine derivative can be combined with another therapy selected from a broad list of therapies including use of a muscarinic antagonist, the publication provides no guidance or reasoning, for example, as to why a particular agent should be selected from the broad list for combination with the clozapine derivative, or why such a combination would be useful. US 5852029, which discloses a particular muscarinic agonist, mentions potential use of the particular agonist with muscarinic antagonists to help eliminate side effects but does not provide any criteria for selecting an appropriate antagonist.

Lack of success by groups such as Maral et al. points to the need to carefully select and ideally test combinations of muscarinic Activators and Inhibitors. Given the impractical nature of physically testing such a large number of combinations, we created an algorithm for in silico testing to perform the extremely difficult task of predicting a priori, without in vivo testing, if a given combination will be efficacious and safe. In order to carry out the in silico testing based on the algorithm, we created an extensive database which captured the known information about muscarinic Activators and Inhibitors. The process by which we created this unique algorithm, as well as the database of muscarinic agents and their properties, was both multi-phased and resource-intensive. First, we created a list of all known muscarinic Activators and Inhibitors. Next, we selected properties of muscarinic agents that are useful in predicting an efficacious and safe combination and determined the relative importance of each property. We then embarked on an exhaustive data-collection process to, wherever possible, gather data related to each property for each muscarinic Activator and Inhibitor. With this data on-hand, we then created a computer-based algorithm, whereby a score is calculated for each property and each combination, such that these scores are then used to generate an overall score for each combination. The scoring system was created such that higher total scores (“Theta Scores”) are applied to combinations with a higher probability to be efficacious with acceptable side effects. Therefore, by testing each combination with the algorithm, we created a prioritized list of combinations whereby combinations with higher scores are more attractive candidates for clinical testing. Given the impracticality of testing every possible combination in vivo, prioritization to select combinations for testing in humans is critical.

In order to evaluate different combinations of muscarinic Activator and Inhibitors, we created a proprietary database of all known muscarinic Activators and Inhibitors (see Tables 1 and 2). This database was created through systematic reviews of a variety of resources in search of all current and past programs related to muscarinic Activators and Inhibitors. Our reviews included scholarly literature databases, such as Pubmed and Web of Science, patent databases, such as Delphion, and pharmaceutical research and development databases, such as Adis R&D InsightTM. We also reviewed drug package inserts, news databases, company websites, and conference abstracts. In all, we reviewed several thousand journal publications, patents, Adis records, and other documents to generate a comprehensive database of 65 muscarinic Activators and 114 muscarinic Inhibitors.

We then selected properties useful in predicting whether a given combination will be efficacious with acceptable side effects. We determined, in other words, the criteria by which each combination may be evaluated in order to generate a quantitative, predictive assessment. This process of selecting relevant properties was driven by rigorous internal analyses and resulted in the identification of several properties that are typically not considered, and/or that are typically thought to be unfavorable, but which we treated as favorable. The combination therapy approach in this application is significantly different from typical combination therapy approaches, which entail looking for synergistic efficacy of two agents. In the present invention, we look for one agent to eliminate the effects of the other agent, which leads to unorthodox criteria for drug selection. For example, we evaluated each muscarinic Inhibitor based on efficacy data such that, in some cases, low or poor efficacy data was rewarded. Also, contrary to typical approaches, in some cases we rewarded muscarinic Inhibitors for the side effects they exhibited during clinical development. Since most muscarinic Inhibitors were tested for unrelated indications, such as overactive bladder, efficacy for these unrelated indications may be undesirable and may be predictive of a combination with potentially unacceptable side effects. For instance, excessive urination is not a commonly reported side effect of muscarinic Activators. Therefore, having Inhibitors that have the greatest ability to decrease micturition may present the greatest risk of causing urinary retention without providing a benefit in the combination.

We rewarded certain side effects, particularly those known to be associated with peripheral anticholinergic effects, because they may counteract or lessen the impact of muscarinic Activator side effects. This combination of rewarding side effects and rewarding poor efficacy leads to the selection of a muscarinic Inhibitor that will have physiological effects throughout the periphery, which is desired for the elimination of muscarinic Activator side effects. For example, if a compound demonstrated efficacy for the treatment of overactive bladder without any side effects, this would suggest that the compound was inhibiting muscarinic receptors in the bladder, but not in the gastrointestinal tract or in the salivary glands to a significant degree. Although such as compound would be ideal for a drug whose intended purpose is the treatment of overactive bladder, such a compound would be unfavorable for the uses described herein. A more favorable Inhibitor for the envisioned combination would demonstrate pharmacological effects (i.e., side effects observed when treating overactive bladder) in the same organs where the Activator causes undesired side effects (e.g., the gastrointestinal tract). The rewarding of side effects and penalizing of efficacy stands in contrast to the typical method for selecting pharmaceutical agents.

Our intensive selection process resulted in 95 relevant properties, on the basis of which each of the 7,410 combinations of known muscarinic Activators and Inhibitors would be evaluated. The properties fell into three general categories: properties related exclusively to muscarinic Activators; properties related exclusively to muscarinic Inhibitors; and properties that combined attributes of both the Activator and Inhibitor. These classifications are discussed below in detail.

To collect data for each muscarinic Activator and Inhibitor based on each property, we embarked on a rigorous data collection process using many of the same resources as those used in generating a database of all known muscarinic Activators and Inhibitors. Again, our review spanned scholarly literature databases, such as Pubmed and Web of Science, patent databases, such as Delphion, pharmaceutical research and development databases, such as Adis R&D InsightTM and the U.S. FDA Orange Book, as well as package inserts and other resources. This process differed, however, in the detailed and often quantitative nature of the information extracted. For example, we gathered and categorized all known efficacy and side effect data for each muscarinic Activator and Inhibitor. We also gathered all known data related to pharmacokinetics and pharmacodynamics. As new data becomes available for compounds currently in our database, or as information regarding potential new entries for our database becomes available, database updates may be made, which would yield new theta scores. For example, MCD 386 is a muscarinic Activator for which additional data could result in increased theta scores for muscarinic Activator and Inhibitor combinations that include MCD 386.

Using these data, we then created a computer-based algorithm to quantify the relative probability that each muscarinic Activator and Inhibitor combination will be efficacious with acceptable side effects. The scoring system functions by applying a score to each combination based on each property, which we call a p-score. Each p-score contributed to an overall calculation, such that a high p-score signified that a combination has an increased likelihood of being efficacious with acceptable side effects based on a given property. Since the algorithm tested a total of 7,410 possible combinations, each of which was evaluated based on 95 p-scores, the algorithm summed a total of 703,950 p-scores in calculating a unique overall score (a “Theta Score”) for each combination (see FIG. 1).

Given the varied nature of data from one property to the next, a variety of scoring methodologies were used to generate p-scores. In all cases, scoring methodologies were consistent within a given property and generated a maximum value of 10, which was then multiplied by a “weight factor.” Weight factors were used to reflect the importance of each property in predicting the probability that a combination is efficacious with acceptable side effects. Some properties, such as those relating to the demonstration of efficacy for an agonist, have a stronger impact in assessing a preferred combination and were thus weighted more heavily. The baseline weight factor for all properties was 1, and the maximum weight factor used was 2.

The primary methodologies used in generating p-scores were ranking-based scoring, binary scoring, and scoring by value cut-off. The mechanics of each of these methodologies are detailed below:

-   -   Ranking-based p-scores were generated using quantitative data,         such as efficacy measurements, and awarding the highest value         (e.g., a score of 10) to the most preferable data point, and the         lowest value (e.g., a score of 0) to the least preferable data         point. The remaining values were then distributed linearly, such         that less preferable data points were awarded proportionally         lower scores. Finally, a weight factor was applied to each value         by multiplying each score by a pre-determined weight that         reflected the importance of the given property. Take, for         example, the case where three muscarinic Inhibitors (Inhibitor         A, Inhibitor B, and Inhibitor C) are evaluated based on the         demonstrated reduction in urinary frequency (number of         micturitions per 24 hours), such that the minimum reduction, or         lowest efficacy, is desired. In this case, Inhibitor A shows a         reduction of 1 micturition per 24 hours, while Inhibitors B and         C show values of 2 and 4 respectively. To calculate each         p-score, since Inhibitor A demonstrated the most desirable         results, we first must give Inhibitor A a proportionally higher         value than B or C (e.g., Inhibitors A, B, and C are given values         of 1, ½, and ¼, respectively). We then linearly distribute these         values such that Inhibitor A receives a score of 10, Inhibitor B         a score of 5, and Inhibitor C a score of 2.5. Finally, these         scores are multiplied by a weight factor, which in this case         would be 1, giving final p-scores of 10, 5, and 2.5.     -   Binary p-scores were generated by assigning one of two values         relating to a binary property. Take, for example, the case of         two muscarinic Activators, A and B, which are evaluated based on         whether they have shown efficacy in human trials. Muscarinic         Activator A, which has shown efficacy, is awarded a value of 10,         while B, which has not, receives a score of 0. Since this         important property has a weight factor of 2, muscarinic         Activators A and B receive final p-scores of 20 and 0,         respectively.     -   Value cut-off p-scores were applied based on the group into         which a given value fell. This methodology was used for         non-binary cases where a ranking methodology is not preferred or         possible (e.g., scoring qualitative data, or scoring         quantitative data in which cut-offs are relevant). In these         cases, muscarinic Activators or Inhibitors whose values fall         into the most desirable category are awarded values of 10 (prior         to multiplication by the corresponding weight factor).

The p-scores applied to each combination were summed to generate three unique Subscores: the Activator Independent Subscore, the Inhibitor Independent Subscore, and the Combination Subscore. The Activator Independent Subscore represents an evaluation of each agonist based on properties that are independent of the antagonist with which it is combined (e.g., the demonstration of efficacy in human trials). Similarly, the Inhibitor Independent Subscore represents an evaluation of each antagonist based on properties that are independent of the agonist with which it is combined (e.g., level of CNS penetrance). The Combination Subscore, in contrast, represents an evaluation based on properties in which characteristics of both the agonist and antagonist are relevant (e.g., similarity of T. based on pharmacokinetic studies). For both the Activator Independent Subscore and the Inhibitor Independent Subscore, the value was calculated by summing each p-score and then normalizing each score such that the highest ranking entry was given a score of 100. Each lower ranking entry was thus increased or decreased proportionally by the same factor as the highest ranking entry. In calculating the Combination Subscore, the same principle was applied; however, the maximum score given was 50.

Ultimately, the algorithm generated a final “Theta Score” for each combination such that, as the theta score increased, so did the probability that the combination would produce efficacy with acceptable side effects. The Theta Score was calculated by summing the three Subscores.

TABLE 1 List of Muscarinic Activators Muscarinic Activators 1 A 72055 2 AF 125 3 AF 150(S) 4 AF 185 5 Alvameline 6 Amifostine 7 Arecoline transdermal-Cogent Pharmaceuticals 8 Cevimeline 9 CI 1017 10 CMI 1145 11 CMI 936 12 CS 932 13 DM 71 14 FPL 14995 15 GSK 1034702 16 Himbacine 17 Itameline 18 KST 2818 19 KSI 5410 20 KST 5452 21 L 670548 22 L 689660 23 L 696986 24 L 705106 25 LY 316108 26 MCD 386 27 Milameline 28 Muscarinic receptor agonists-ACADIA/Allergan 29 NC 111585 30 Nebracetam 31 NGX 267 32 Norclozapine 33 ORG 20091 34 PD 141606 35 PD 142505 36 PD 151832 37 PDC 008004 38 Pilocarpine 39 Pilocarpine-Controlled Therapeutics 40 PTAC 41 Anavex Life Sciences preclinical muscarinic activator 42 Eli Lilly preclinical M1 receptor muscarinic activator 43 Eli Lilly preclinical M4 receptor muscarinic activator 44 TorryPines Therapeutics preclinical muscarinic activator 45 Banyu preclinical muscarinic activator 46 Mithridion preclinical muscarinic activator 47 ACADIA/Sepracor preclinical muscarinic activator 48 ACADIA preclinical muscarinic activator 49 RU 35963 50 Sabcomeline 51 SDZ 210086 52 SR 46559A 53 SR 96777A 54 Stacofylline 55 Talsaclidine 56 Tazomeline 57 Thiopilocarpine 58 Ticalopride 59 U 80816 60 Vedadidine 61 WAY 131256 62 WAY 132983 63 Xanomeline 64 YM 796 65 YM 954

TABLE 2 List of Muscarinic Inhibitors Muscarinic Inhibitors 1 Aclidinium bromide 2 Aclidinium bromide/formoterol 3 Acotiamide 4 AH 9700 5 Alvameline 6 AQRA 721 7 AQRA 741 8 AZD 9164 9 BIBN 99 10 CEB 1957 11 Clozapine extended release-Azur Pharma 12 Darenzepine 13 Darifenacin 14 Darotropium bromide 15 Dextro-mequitamium iodide 16 Ebeinone 17 Esoxybutynin 18 Espatropate 19 Fesoterodine 20 Glycopyrrolate/indacaterol 21 Glycopyrronium bromide 22 GSK 1160724 23 GSK 202405 24 GSK 573719 25 GSK 656398 26 GSK 961081 27 GYKI 46903 28 Homatropine methylbromide 29 Imidafenacin 30 Inhaled glycopyrrolate-Novartis 31 Ipratropium bromide dry-powder inhalation-Dura/Spiros 32 Ipratropium bromide dry-powder inhalation-ML Laboratories 33 Ipratropium bromide hydrofluoroalkane inhalatior-Boehringer Ingelheim 34 Ipratropium bromide intranasal-Chiesi 35 Ipratropium bromide metered solution inhalation-Sheffield 36 Ipratropium bromide/xylometazoline 37 J 104129 38 J 106366 39 L 696986 40 LAS 35201 41 Levosalbutamol/ipratropium inhalation solution- Arrow International Limited/Sepracor 42 Liriodenine 43 LK 12 44 Mequitamium iodide 45 Methantheline 46 Methantheline bromide 47 Methscopolamine bromide 48 N-butylscopolamine 49 N-methylatropine 50 NPC 14695 51 NX 303 52 Otenzepad 53 Oxybutynin-Labopharm 54 Oxybutynin-Penwest Pharmaceuticals 55 Oxybutynin chloride-ALZA 56 Oxybutynin intravesical-Situs 57 Oxybutynin transdermal-Schwarz Pharma 58 Oxybutynin transdermal-Watson 59 Oxybutynin transdermal gel-Antares 60 Oxvbutynin transmucosal-Auxilium 61 Oxybutynin vaginal-Barr Laboratories 62 PG 1000 63 Pirenzepine ophthalmic 64 Pirmenol 65 PNU 200577 66 Promethazine/hydrocodone/paracetamol-Charleston Laboratories 67 Propantheline 68 Propantheline bromide 69 Propiverine 70 PSD 506 71 PTAC 72 QAT 370 73 Almirall muscarinic Inhibitor 74 Anavex Life Sciences primary muscarinic Inhibitor 75 Anavex Life Sciences secondary muscarinic inhibitor 76 FF2-Nuada 77 GlaxoSmithKline/Theravance muscarinic Inhibitor 78 Chiesi Farmaceutici/SALVAT muscarinic inhibitor 79 UCB muscarinic Inhibitor 80 Theravance primary muscarinic Inhibitor 81 Theravance secondary muscarinic Inhibitor 82 Novartis muscarinic Inhibitor 83 ACADIA/Sepracor muscarinic Inhibitor 84 Safetek muscarinic Inhibitor 85 Revatropate 86 Rispenzepine 87 RL 315535 88 RO 465934 89 SCH 211803 90 SCH 57790 91 Scopolamine intranasal-Nastech 92 Scopolamine transmucosal-Anesta 93 Secoverine 94 S-ET 126 95 Sintropium bromide 96 Solifenacin 97 Solifenacin/tamsulosin 98 SVT 40776 99 TD 6301 100 Telenzepine 101 Temiverine 102 Tiotropium bromide 103 Tolterodine 104 Tolterodine/tamsulosin 105 Tropenzilium 106 Trospium chloride 107 Trospium chloride controlled release 108 Trospium chloride inhalation 109 V 0162 110 YM 35636 111 YM 46303 112 YM 53705 113 YM 58790 114 Zamifenacin

The algorithm was structured with inputs according to the following 3 tables. The Property, Scoring Methodology, Criteria for a High Score, and Weight columns in each table represent the underlying inputs and mechanics used in calculating each Subscore.

TABLE 3 Mechanics of Activator Independent Subscore Activator Subscore Mechanics Criteria for a Weight Count Property Category Property Scoring Methodology High Score Factor 1 Development Highest Phase Unique value assigned to High stage of 1 each dev. stage development 2 Development Highest Phase CNS Unique value assigned to High stage of 1 each dev. stage development 3 Development Highest Phase US Unique value assigned to High stage of 1 each dev. stage development 4 ROA Route of Unique value assigned to Oral 1 Administration each RDA 5 Pharmakinetics Tmax Ranked by Tmax value High Tmax 1 5 Pharmakinetics T(½) Ranked by T(½) value HIgh T(½) 1 7 Efficacy Demonstrated Efficacy Binary scoring Efficacy Shown 2 8 Efficacy Demonstrated Efficacy Binary scoring Efficacy Shown 2 Cognition 9 Efficacy Demonstrated Efficacy Binary scoring Efficacy Shown 2 Schizophrenia 10 Receptor Selectivity M2 Agonist? Binary scoring Not M2 Agonist 1 11 Receptor Selectivity M3 Agonist? Binary scoring Not M3 Agonist 1 12 Receptor Selectivity M1/M2 ratio Ranked by ratio volume High ratio 1 13 Receptor Selectivity M1/M3 ratio Ranked by ratio volume High ratio 1 14 Receptor Selectivity M1/M5 ratio Ranked by ratio volume High ratio 1 15 Receptor Selectivity M4/M2 ratio Ranked by ratio volume High ratio 1 16 Receptor Selectivity M4/M3 ratio Ranked by ratio volume High ratio 1 17 Receptor Selectivity M4/M5 ratio Ranked by ratio volume High ratio 1 18 Receptor Selectivity M2/M3 ratio Ranked by ratio volume Close to 1 1 19 Receptor Selectivity M5/M2 ratio Ranked by ratio volume Close to 1 1 20 Receptor Selectivity M5/M3 ratio Ranked by ratio volume Close to 1 1

TABLE 4 Mechanics of Inhibitor Independent Subscore Inhibitor Subscore Mechanics Criteria for Weight Count Property Category Property Scoring Methodology High Score Factor 1 Development Highest Phase Unique value assigned to High stage of 1 each dev. stage development 2 Development Highest Phase US Unique value assigned to High stage of 1 each dev. stage development 3 ROA Route of Administration Unique value assigned to Oral 1 each ROA 4 Pharmacokinetics Tmax Ranked by Tmax value High Tmax 1 5 Pharmacokinetics T(½) Ranked by T(½) value High T(½) 1 6 CNS Penetrance CNS Penetrance Unique value assigned based Low penetrance 2 on H, M, L penetrance 7 Receptor Selectivity M2/M1 ratio Ranked by ratio value High ratio 8 Receptor Selectivity M2/M4 ratio Ranked by ratio value High ratio 1 9 Receptor Selectivity M3/M1 ratio Ranked by ratio value High ratio 1 10 Receptor Selectivity M3/M4 ratio Ranked by ratio value High ratio 1 11 Efficacy Urinary Frequency Ranked by efficacy value Low efficacy 1 (# Micturitions per 24 hrs)- Reduction 12 Efficacy Urinary Frequency Ranked by efficacy value Low efficacy 1 (# Micturitions/24 hrs)- % Reduction 13 Efficacy Urinary Frequency Ranked by efficacy value Low efficacy (# Micturitions/24 hrs)- % Reduction over Placebo 14 Efficacy Urinary Frequency Ranked by efficacy value Low efficacy 1 (# Micturitions/24 hrs)- Reduction over Placebo 15 Efficacy Volume Voided/micturition Ranked by efficacy value Low efficacy 1 (mL)-Reduction 16 Efficacy Volume Voided/micturition Ranked by efficacy value Low efficacy 1 (mL)-% Reduction 17 Efficacy Volume Voided/micturition Ranked by efficacy value Low efficacy 1 (mL)-% Reduction over Placebo 18 Efficacy Volume Voided/micturition Ranked by efficacy value Low efficacy 1 (mL)-Reduction over Placebo 19 Efficacy # of Incontinence Eps/ Ranked by efficacy value Low efficacy 1 24 hours-% Reduction 20 Efficacy # of Incontinence Eps/ Ranked by efficacy value Low efficacy 1 24 hours-Reduction 21 Efficacy # of Incontinence Eps/ Ranked by efficacy value Low efficacy 1 week-% Reduction 22 Efficacy # of Incontinence Eps/ Ranked by efficacy value Low efficacy 1 week-Reduction 23 Efficacy # Urge incontinence eps/ Ranked by efficacy value Low efficacy 1 24 hrs-% Reduction 24 Efficacy # Urge incontinence eps/ Ranked by efficacy value Low efficacy 1 24 hrs-Reduction 25 Efficacy # Urge incontinence eps/ Ranked by efficacy value Low efficacy 1 week-% Reduction 26 Efficacy # Urge incontinence eps/ Ranked by efficacy value Low efficacy 1 week-Reduction 27 Adverse Events Dry Mouth-% increase Ranked by AE value LowAE values 1 over placebo 28 Adverse Events Constipation-% increase Ranked by AE value Low AE values 1 over placebo 29 Adverse Events Dyspepsia-% increase Ranked by AE value Low AE values 1 over placebo 30 Adverse Events Abdominal Pain-% Ranked by AE value Low AE values 1 increase over placebo 31 Adverse Events Dry Mouth-absolute % Ranked by AE value Low AE values 1 values 32 Adverse Events Constipation-absolute % Ranked by AE value Low AE values 1 values 33 Adverse Events Dyspepsia-absolute % Ranked by AE value Low AE values 1 values 34 Adverse Events Abdominal Pain- Ranked by AE value Low AE values 1 absolute % values 35 Adverse Events Constipation aggravated Ranked by AE value Low AE values 1 36 Adverse Events Nausea Ranked by AE value Low AE values 1 37 Adverse Events Abdominal Distension Ranked by AE value Low AE values 1 38 Adverse Events Flatulence Ranked by AE value Low AE values 1 39 Adverse Events Diarrhea Ranked by AE value Low AE values 1 40 Adverse Events Vomiting Ranked by AE value Low AE values 1 41 Adverse Events UTI Ranked by AE value Low AE values 1 42 Adverse Events Upper Respiratory tract Ranked by AE value Low AE values 1 infection 43 Adverse Events Influenza Ranked by AE value Low AE values 1 44 Adverse Events Pharyngitis Ranked by AE value Low AE values 1 45 Adverse Events Headache Ranked by AE value Low AE values 1 46 Adverse Events Dizziness Ranked by AE value Low AE values 1 47 Adverse Events Vision Blurred Ranked by AE value Low AE values 1 48 Adverse Events Dry Eyes Ranked by AE value Low AE values 1 49 Adverse Events Urinary Retention Ranked by AE value Low AE values 1 50 Adverse Events Dysuria Ranked by AE value Low AE values 1 51 Adverse Events Edema Lower Limb Ranked by AE value Low AE values 1 52 Adverse Events Edema peripheral Ranked by AE value Low AE values 1 53 Adverse Events Fatigue Ranked by AE value Low AE values 1 54 Adverse Events Depression Ranked by AE value Low AE values 1 55 Adverse Events Insomnia Ranked by AE value Low AE values 1 56 Adverse Events Cough Ranked by AE value Low AE values 1 57 Adverse Events Dry Throat Ranked by AE value Low AE values 1 58 Adverse Events Hypertension Ranked by AE value Low AE values 1 59 Adverse Events Asthenia Ranked by AE value Low AE values 1 60 Adverse Events Nasal dryness Ranked by AE value Low AE values 1 61 Adverse Events Back pain Ranked by AE value Low AE values 1 62 Adverse Events ALT increased Ranked by AE value Low AE values 1 63 Adverse Events GGT increased Ranked by AE value Low AE values 1 64 Adverse Events Rash Ranked by AE value Low AE values 1 Note: ALT = Alanine transaminase; GGT = Gamma-glutamyltransferase

TABLE 5 Mechanics of Combination Subscore CombinationSubscore Mechanics Property Scoring Criteria for a Weight Count Category Property Methodology High Score Factor 1 Pharmaco- Tmax Unique value given based on Close Tmax values 1 kinetics closeness of Tmax 2 Pharmaco- T(½) Unique value given based on Close T(½) values 1 kinetics closeness of T(½) 3 Metabolism Drug-drug interaction Unique value assigned based on Low overall risk of drug-drug 1 potential H, M, or L degree of interaction, interaction specifically regarding CYP 450 4 Receptor (M1 Activator selectivity/M1 Ranked by ratio value High ratio value (devalue if 1 Selectivity Inhibitor selectivity) ratio Inhibitor acts on M1, Activator is weak M1 Activator) 5 Receptor (M4 Activator selectivity/M4 Ranked by ratio value High ratio value (devalue if 1 Selectivity Inhibitor selectivity) ratio Inhibitor acts on M4, Activator is weak M4 Activator) 6 Receptor (M3 Activator selectivity/M3 Ranked by ratio value Low ratio value (With M3 1 Selectivity Inhibitor selectivity) ratio Activator, M3 Inhibitor is desired) 7 Receptor (M2 Activator selectivity/M2 Ranked by ratio value Low ratio value (If M2 1 Selectivity Inhibitor selectivity) ratio Activator, M2 Inhibitor is desired) 8 Receptor (M5 Activator selectivity/M5 Ranked by ratio value High ratio value 1 Selectivity Inhibitor selectivity) ratio 9 Receptor M2/M3 ratio comparison Ranked by ratio value Ratio value close to 1 1 Selectivity 10 Efficacy Reward specific cases of Case specific Case specific 1 Inhibitor AEs if “offsetting” an Activator AE 11 Adverse Events Reward specific cases of Case specific Case specific 1 Inhibitor AEs if “offsetting” an Activator AE Note: In cases where an Activator inhibits a receptor, or where an Inhibitor activates a receptor, receptor selectivity ratios are changed to equal one divided by the ratio for determining the p-score.

TABLE 6 Top 15 Combinations by Theta Score Activator Inhibitor Combination Theta Independent Independent Combination ID Combination Score Subscore Subscore Subscore 6355 Xanomeline & Trospium chloride 250 100 100 50 5003 Sabcomeline & Trospium chloride 245 95 100 50 2611 Milameline & Trospium chloride 243 98 100 45 6346 Xanomeline & Tolterodine 241 100 91 50 2602 Kililameline & Tolterodine 239 98 91 50 5005 Sabcomeline & Trospium chloride 238 95 93 50 controlled release 6357 Xanomeline & Trospium chloride 238 100 93 45 controlled release 2613 Milameline & Trospium chloride 236 98 93 45 controlled release 6347 Xanomeline & Darifenacin 235 100 95 40 6348 Xanomeline & Solifenacin 234 100 94 40 4996 Sabcomeline & Solifenacin 229 95 94 40 5523 Talsaclidine & Trospium chloride 224 94 100 30 635 Cevimeline & Trospium chloride 219 89 100 30 5515 Talsaclidine & Darifenacin 219 94 95 30 5516 Talsaclidine & Solifenacin 218 94 94 30 5525 Talsaclidine & Trospium chloride 217 94 93 30 controlled release 5514 Talsaclidine & Tolterodine 215 94 91 30 6349 Xanomeline & Fesoterodine 215 100 85 30 627 Cevimeline & Darifenacin 214 89 95 30 637 Cevimeline & Trospium chloride 212 89 93 30 controlled release

TABLE 7 Further list of Muscarinic Activators Muscarinic Activators NSX0527 NSX0559 AF710B Anavex 141 HTL9936 HTL18318 1-((1H-indazol-5-yl)sulfoneyl)-N-ethyl-N-(2- (trifluoromethyl)benzyl)piperidine-4-carboxamide (ML380) VU0152100 VU0255035 [3H]PT-1284 LY2119620 VU0238429 Thiochrome VU152099 LY2033928 ML173 ML293 AC-42 N-desmethylclozapine 77-LH-28-1 VU0184670 VU0357017 VU0364572 Brucine BQCA PQCA ML-137 ML-169 VU0405652

In a preferred embodiment of the invention, a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 230 or greater as determined by in silico testing using the above described algorithm is used. In another embodiment of the invention, a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 200 or greater as determined by in silico testing using the above described algorithm is used. In another embodiment of the invention, a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 150 or greater as determined by in silico testing using the above described algorithm is used. In a further embodiment of the invention, a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 149 or lower as determined by in silico testing using the above described algorithm is used.

In one embodiment, xanomeline is used as the muscarinic Activator in combination with the muscarinic Inhibitor. In another embodiment, xanomeline is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, xanomeline is administered from one time to three times during a 24 hour period. In another embodiment, from 25 milligrams to 700 milligrams of xanomeline is used during a 24 hour period. In a preferred embodiment, from 75 milligrams to 300 milligrams of xanomeline is used during a 24 hour period.

In one embodiment, sabcomeline is used as the muscarinic Activator in combination with the muscarinic Inhibitor. In another embodiment, sabcomeline is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, sabcomeline is administered from one to three times during a 24 hour period. In another embodiment, from 50 micrograms to five milligrams of sabcomeline is used during a 24 hour period. In a preferred embodiment, from 150 micrograms to 450 micrograms of sabcomeline is used during a 24 hour period.

In one embodiment, milameline is used as the muscarinic Activator in combination with the muscarinic Inhibitor. In another embodiment, milameline is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, milameline is administered from one to three times during a 24 hour period. In another embodiment, from 0.5 milligrams to 50 milligrams of milameline is used during a 24 hour period. In a preferred embodiment, from four milligrams to 16 milligrams of milameline is used during a 24 hour period.

In one embodiment, talsaclidine is used as the muscarinic Activator in combination with the muscarinic Inhibitor. In another embodiment, talsaclidine is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, talsaclidine is administered from one to three times during a 24 hour period. In another embodiment, from five milligrams to 1 gram of talsaclidine is used during a 24 hour period. In a preferred embodiment, from 120 milligrams to 480 milligrams of talsaclidine is used during a 24 hour period.

In one embodiment, cevimeline is used as the muscarinic Activator in combination with the muscarinic Inhibitor. In another embodiment, cevimeline is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, cevimeline is administered from one to three times during a 24 hour period. In another embodiment, from 45 milligrams to 750 milligrams of cevimeline is used during a 24 hour period. In a preferred embodiment, from 90 milligrams to 360 milligrams of cevimeline is used during a 24 hour period.

In one embodiment, pilocarpine is used as the muscarinic Activator in combination with the muscarinic Inhibitor. In another embodiment, pilocarpine is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, pilocarpine is administered from one to three times during a 24 hour period. In another embodiment, from 7.5 milligrams to 500 milligrams of pilocarpine is used during a 24 hour period. In a preferred embodiment, from 30 milligrams to 200 milligrams of pilocarpine is used during a 24 hour period.

In one embodiment, trospium chloride is used as the muscarinic Inhibitor in combination with the muscarinic Activator. In another embodiment, trospium chloride is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, trospium chloride is administered from one time to three times during a 24 hour period. In another embodiment, from five milligrams to 400 milligrams of trospium chloride is used during a 24 hour period. In a preferred embodiment, from 20 milligrams to 200 milligrams of trospium chloride is used during a 24 hour period.

In one embodiment, trospium chloride extended release is used as the muscarinic Inhibitor in combination with the muscarinic Activator. In another embodiment, trospium chloride extended release is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, trospium chloride extended release is administered from one to three times during a 24 hour period. In another embodiment, from five milligrams to 400 milligrams of trospium chloride extended release is used during a 24 hour period. In a preferred embodiment, from 20 milligrams to 200 milligrams of trospium chloride extended release is used during a 24 hour period.

In one embodiment, solifenacin is used as the muscarinic Inhibitor in combination with the muscarinic Activator. In another embodiment, solifenacin is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, solifenacin is administered from one time to three times during a 24 hour period. In another embodiment, from 0.25 milligrams to 100 milligrams of solifenacin is used during a 24 hour period. In a preferred embodiment, from 1 milligram to 30 milligrams of solifenacin is used during a 24 hour period.

In one embodiment, tolterodine is used as the muscarinic Inhibitor in combination with the muscarinic Activator. In another embodiment, tolterodine is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, tolterodine is administered from one to three times during a 24 hour period. In another embodiment, from one milligram to 16 milligrams of tolterodine is used during a 24 hour period. In a preferred embodiment, from two milligrams to eight milligrams of tolterodine is used during a 24 hour period.

In one embodiment, fesoterodine is used as the muscarinic Inhibitor in combination with the muscarinic Activator. In another embodiment, fesoterodine is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, fesoterodine is administered from one to three times during a 24 hour period. In another embodiment, from two milligrams to 56 milligrams of fesoterodine is used during a 24 hour period. In a preferred embodiment, from four milligrams to 28 milligrams of fesoterodine is used during a 24 hour period.

In one embodiment, darifenacin is used as the muscarinic Inhibitor in combination with the muscarinic Activator. In another embodiment, darifenacin is administered to a patient from one time to five times during a 24 hour period. In a preferred embodiment, darifenacin is administered from one to three times during a 24 hour period. In another embodiment, from 3.75 milligrams to 150 milligrams of darifenacin is used during a 24 hour period. In a preferred embodiment, from 7.5 milligrams to 30 milligrams of darifenacin is used during a 24 hour period.

In one embodiment, xanomeline is administered as a muscarinic Activator in combination with trospium chloride as a muscarinic Inhibitor. In another embodiment, 225 mg of xanomeline as a muscarinic Activator and 40 mg of trospium chloride as a muscarinic Inhibitor are administered to a patient in a 24 hour period. In a further embodiment, 75 mg of xanomeline as a muscarinic Activator is administered three times a day, and 20 mg of trospium chloride as a muscarinic Inhibitor is administered twice a day, to a patient in a 24 hour period.

While the subject is being treated, the health of the patient may be monitored by measuring one or more of the relevant indices at predetermined times during the treatment period. Treatment, including composition, amounts, times of administration and formulation, may be optimized according to the results of such monitoring. The patient may be periodically reevaluated to determine the extent of improvement by measuring the same parameters. Adjustments to the amount(s) of subject composition administered and possibly to the time of administration may be made based on these reevaluations.

Treatment may be initiated with smaller dosages that are less than the optimum dose of the compound. Thereafter, the dosage may be increased by small increments until the optimum balance between therapeutic effect and side effects is attained.

Dosage Forms of the Combination

In one embodiment, the muscarinic Activator and muscarinic Inhibitor are in different dosage forms or dosage vehicles. In a preferred embodiment, the muscarinic Activator and muscarinic Inhibitor are in the same dosage form or dosage vehicles. The dosage forms may include one or more pharmaceutically-acceptable carriers. The dosage forms may also include one or more pharmaceutically-acceptable salts. The dosage forms may be administered orally. The Activator and Inhibitor may be delivered orally using tablets, troches, liquids, emulsions, suspensions, drops, capsules, caplets or gel caps and other methods of oral administration known to one skilled in the art. The muscarinic Activator and Inhibitor may also be administered parentally. Other routes of administration include but are not limited to: topical, transdermal, nasal, ocular, rectal, sublingual, inhalation, and vaginal. For topical and transdermal administration, the Activator and Inhibitor may be delivered in a cream, gel, ointment, spray, suspension, emulsion, foam, or patch or by other methods known to one skilled in the art. For nasal administration, the Activator and Inhibitor may be delivered by sprays, drops, emulsions, foams, creams, ointments or other methods known to one skilled in the art. For nasal administration, formulations for inhalation may be prepared as an aerosol, either a solution aerosol in which the active agent is solubilized in a carrier, such as a propellant, or a dispersion aerosol, in which the active agent is suspended or dispersed throughout a carrier and an optional solvent. For ocular administration, the Activator and Inhibitor may be delivered in drops, sprays, injections, solutions, emulsions, suspensions, or ointments, or by other methods known to one skilled in the art. For rectal administration, the Activator and Inhibitor may be delivered using suppositories, enemas, creams, foams, gels, or ointments or by other methods known to one skilled in the art. For sublingual administration, the Activator and Inhibitor may be delivered in tablets, troches, liquids, emulsions, suspensions, drops, capsules, caplets or gel caps and by other methods of oral administration known to one skilled in the art. For administration by inhalation, the Activator and Inhibitor may be delivered in vapor, mist, powder, aerosol, or nebulized form, or by other methods known to one skilled in the art. For vaginal administration, the Activator and Inhibitor may be delivered in solutions, emulsions, suspensions, ointments, gels, foams, or vaginal rings or by other methods known to one skilled in the art.

The muscarinic Activator and Inhibitor may be in a dosage form that immediately releases the drug. In an alternative embodiment, the muscarinic Activator and Inhibitor are in a controlled release dosage form. In one embodiment of the controlled release dosage form, the Activator and Inhibitor have similar release kinetics. In another embodiment, the Inhibitor is released prior to the Activator's being released. In another embodiment, a three part release profile is used such that the Inhibitor is released immediately, followed by the Activator in a controlled release fashion and then by the Inhibitor in a controlled release fashion. In one embodiment, the muscarinic Activator and Inhibitor are packaged in liposomes. In a further embodiment, the liposome comprises a phospholipid. In a further embodiment, the phospholipid in the liposome is selected from phosphatidylcholine (PC), phosphatidylglycerol (PG), phosphatidylinositol (PI), phosphatidylserine (PS), phosphatidylethanolamine (PE), phosphatidic acid (PA), egg phosphatidylcholine (EPC), egg phosphatidylglycerol (EPG), egg phosphatidylinositol (EPI), egg phosphatidylserine (EPS), egg phosphatidylethanolamine (EPE), egg phosphatidic acid (EPA), soy phosphatidylcholine (SPC), soy phosphatidylglycerol (SPG), soy phosphatidylserine (SPS), soy phosphatidylinositol (SPI), soy phosphatidylethanolamine (SPE), soy phosphatidic acid (SPA), hydrogenated egg phosphatidylcholine (HEPC), hydrogenated soy phosphatidylcholine (HSPC), dipalmitoylphosphatidylcholine (DPPC), dioleoylphosphatidylcholine (DOPC), dimyristoylphosphatidylcholine (DMPC), dimyristoylphosphatidylglycerol (DMPG), dipalmitoylphosphatidylglycerol (DPPG), di stearoylphosphatidylcholine (DSPQ), di stearoylphosphatidylglycerol (DSPG), dioleoylphosphatidyl-ethanolamine (DOPE), palmitoylstearoylphosphatidyl-choline (PSPC), palmitoylstearolphosphatidylglycerol (PSPG), mono-oleoyl-phosphatidylethanolamine (MOPE), dilauroyl ethylphosphocholine (DLEP), dimyristoyl ethylphosphocholine (DMEP), dipalmitoyl ethylphosphocholine (DPEP), distearoyl ethylphosphocholine (DSEP), dimyristoylphosphatidic acid (DMPA), dipalmitoylphosphatidic acid (DPPA), distearoylphosphatidic acid (DSPA), dimyristoylphosphatidylinositol (DMPI), dipalmitoylphosphatidylinositol (DPPI), di stearoylphosphatidylinositol (DSPI), dimyristoylphosphatidylserine (DMPS), dipalmitoylphosphatidylserine (DPPS), distearoylphosphatidylserine (DSPS), N-acylated phosphorylethanolamine (NAPE), and combinations thereof

In a further embodiment, the controlled release formulation comprises a semi-permeable membrane. The muscarinic Activator and muscarinic Inhibitor may be in different membranes in the same formulation. In another embodiment, the muscarinic Activator and muscarinic Inhibitor can be in different membranes in different formulations or dosing vehicles. In a further embodiment, the semi-permeable membrane comprises a polymer. In a further embodiment, the controlled release formulation comprises a matrix that suspends the muscarinic Activator(s) and muscarinic Inhibitor(s). The muscarinic Activator and Inhibitor may be in separate matrices within the same medicament. In a further embodiment, the matrix comprises a polymer. In a further embodiment, the polymer comprises a water soluble polymer. In a further embodiment, the water soluble polymer is selected from Eudragit RL, polyvinyl alcohol, polyvinylpyrrolidone, methyl cellulose, hydroxypropyl cellulose, hydroxypropylmethyl cellulose, polyethylene glycol, and mixtures thereof. In a further embodiment, the polymer comprises a water insoluble polymer. In a further embodiment, the water insoluble polymer is selected from Eudragit RS, ethylcellulose, cellulose acetate, cellulose propionate, cellulose acetate propionate, cellulose acetate butyrate, cellulose acetate phthalate, cellulose triacetate, poly(methyl methacrylate), poly(ethyl methacrylate), poly(butyl methacrylate), poly(isobutyl methacrylate), poly(hexyl methacrylate), poly(isodecyl methacrylate), poly(lauryl methacrylate), poly(phenyl methacrylate), poly(methyl acrylate), poly(isopropyl acrylate), poly(isobutyl acrylate), poly(octadecyl acrylate), poly(ethylene), poly(ethylene) low density, poly(ethylene) high density, poly(propylene), poly(ethylene terephthalate), poly(vinyl isobutyl ether), poly(vinyl acetate), poly(vinyl chloride), polyurethane, and mixtures thereof. In a further embodiment, the matrix comprises a fatty compound. In a further embodiment, the fatty compound is a wax or glyceryl tristearate. In a further embodiment, the polymer comprises a water soluble polymer and a water insoluble polymer. In a further embodiment, the matrix further comprises a fatty compound.

The muscarinic Activator and muscarinic Inhibitor may be in dosage forms that use other methods of controlled release formulation known to one skilled in the art (for example, Dixit & Puthli. J. Control Release. 2:94. 2009; Mizrahi & Domb. Recent Pat Drug Deliv Formul. 2:108. 2008; Forqueri & Singh. Recent Pat Drug Deliv Formul. 3:40. 2009; Kalantzi et al. Recent Pat Drug Deliv Formul. 3:49. 2009; Iconomopoulou et al. Recent Pat Drug Deliv Formul. 2:94. 2008; Panos et al. Curr Drug Discov Technol. 5: 333. 2008; 2008. Wan et al. Nanomed. 2:483. 2007. Wang et al. Drug Delivery: Principles & Applications. Wiley 2005).

In another embodiment, the combination of the muscarinic Activator and Inhibitor is used in combination with one or more therapies that can include both psychotherapy and drugs. Therapeutic agents include but are not limited to antipsychotics, anxiolytics, anti-depressants, sedatives, tranquilizers and other pharmacological interventions known to one skilled in the art. A therapeutic agent may fall under the category of more than one type of drug. For instance benzodiazepines can be considered anxiolytics, sedatives and tranquilizers.

Medicament Containing One or More Muscarinic Activators & Muscarinic Inhibitors

One embodiment of the invention is a medicament comprising one or more muscarinic Activators and one or more muscarinic Inhibitors.

In one embodiment, from 10 micrograms to 10 grams of Activator is used in the combination with the Inhibitor in the medicament. In another embodiment, from 1 milligram to 1 gram of Activator is used in the combination with the Inhibitor. In another embodiment from 10 micrograms to 10 grams of Inhibitor is used in the combination with the Activator. In another embodiment, from 1 milligram to 1 gram of Inhibitor is used in the combination with the Activator.

In one embodiment, the medicament is administered to a patient 6 times during a 24 hour period. In another embodiment, the medicament is administered to a patient 5 times during a 24 hour period. In another embodiment, the medicament is administered to a patient 4 times during a 24 hour period. In another embodiment, the medicament is administered to a patient 3 times during a 24 hour period. In another embodiment, the medicament is administered to a patient 2 times during a 24 hour period. In another embodiment, the medicament is administered to a patient one time during a 24 hour period. In a preferred embodiment, the medicament is administered from one to 3 times during a 24 hour period.

In one embodiment of the invention, the medicament contains a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 230 or greater as determined by in silico testing using the above described algorithm. In another embodiment of the invention, the medicament contains a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 200 or greater as determined by in silico testing using the above described algorithm. In another embodiment of the invention, the medicament contains a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 150 or greater as determined by in silico testing using the above described algorithm. In a further embodiment of the invention, the medicament contains a combination of a muscarinic Activator and a muscarinic Inhibitor with a theta score of 149 or lower as determined by in silico testing using the above described algorithm. In a further embodiment, xanomeline is used as the muscarinic Activator in the medicament. In another embodiment, the medicament contains from five milligrams to 700 milligrams of xanomeline. In a preferred embodiment, the medicament contains from 25 milligrams to 300 milligrams of xanomeline.

In one embodiment, sabcomeline is used as the muscarinic Activator in the medicament. In another embodiment, the medicament contains from 10 micrograms to five milligrams of sabcomeline. In a preferred embodiment, the medicament contains from 50 micrograms to 450 micrograms of sabcomeline.

In one embodiment, milameline is used as the muscarinic Activator in the medicament. In another embodiment, the medicament contains from 0.1 milligrams to 50 milligrams of milameline. In a preferred embodiment, the medicament contains from one milligram to 16 milligrams of milameline.

In one embodiment, talsaclidine is used as the muscarinic Activator in the medicament. In another embodiment, the medicament contains from one milligram to one gram of talsaclidine. In a preferred embodiment, the medicament contains from 40 milligrams to 480 milligrams of talsaclidine.

In one embodiment, cevimeline is used as the muscarinic Activator in the medicament. In another embodiment, the medicament contains from nine milligrams to 750 milligrams of cevimeline. In a preferred embodiment, the medicament contains from 30 milligrams to 360 milligrams of cevimeline.

In one embodiment, pilocarpine is used as the muscarinic Activator in the medicament. In another embodiment, the medicament contains from 1.5 milligrams to 500 milligrams of pilocarpine. In a preferred embodiment, the medicament contains from 10 milligrams to 200 milligrams of pilocarpine.

In one embodiment, trospium chloride is used as the muscarinic Inhibitor in the medicament. In another embodiment, the medicament contains from one milligram to 400 milligrams of trospium chloride. In a preferred embodiment, the medicament contains from 6.5 milligrams to 200 milligrams of trospium chloride.

In one embodiment, trospium chloride extended release is used as the muscarinic Inhibitor in the medicament. In another embodiment, the medicament contains from one milligram to 400 milligrams of trospium chloride extended release. In a preferred embodiment, the medicament contains from 6.5 milligrams to 200 milligrams of trospium chloride extended release.

In one embodiment, solifenacin is used as the muscarinic Inhibitor in the medicament. In another embodiment, the medicament contains from 0.25 milligram to 100 milligrams of solifenacin. In a preferred embodiment, the medicament contains from 1 milligrams to 30 milligrams of solifenacin.

In one embodiment, tolterodine is used as the muscarinic Inhibitor in the medicament. In another embodiment, the medicament contains from 0.2 milligrams to 16 milligrams of tolterodine. In a preferred embodiment, the medicament contains from 0.7 milligrams to eight milligrams of tolterodine.

In one embodiment, fesoterodine is used as the muscarinic Inhibitor in the medicament. In another embodiment, the medicament contains from 0.4 milligrams to 56 milligrams of fesoterodine. In a preferred embodiment, the medicament contains between one milligrams to 28 milligrams of fesoterodine.

In one embodiment, darifenacin is used as the muscarinic Inhibitor in the medicament. In another embodiment, the medicament contains from n 0.8 milligrams to 150 milligrams of darifenacin. In a preferred embodiment, the medicament contains from 2.5 milligrams to 30 milligrams of darifenacin.

In a further embodiment, xanomeline is used as the muscarinic Activator in the medicament, and trospium chloride is used as the muscarinic Inhibitor in the same medicament. In another embodiment, xanomeline is used as the muscarinic Activator in the medicament, and trospium chloride is used as the muscarinic Inhibitor in a different medicament. In a preferred embodiment, the medicament contains 75 mg or 225 milligrams of xanomeline, and the same medicament contains 20 mg or 40 milligrams of trospium chloride. In another preferred embodiment, the medicament contains 75 mg or 225 milligrams of xanomeline, and a different medicament to be co-administered contains 20 mg or 40 milligrams of trospium chloride.

While the subject is being treated, the health of the patient may be monitored by measuring one or more of the relevant indices at predetermined times during the treatment period. Treatment, including composition, amounts, times of administration and formulation, may be optimized according to the results of such monitoring. The patient may be periodically reevaluated to determine the extent of improvement by measuring the same parameters. Adjustments to the amount(s) of subject composition administered and possibly to the time of administration may be made based on these reevaluations.

Treatment may be initiated with smaller dosages that are less than the optimum dose of the compound. Thereafter, the dosage may be increased by small increments until the optimum balance between therapeutic effect and side effects is attained. This principle of drug titration is well understood by those of skill in the art.

The medicament may also include one or more pharmaceutically-acceptable salts. The medicament may include one or more pharmaceutically-acceptable carriers. The medicament may be administered orally. The medicament may be delivered orally using tablets, troches, liquids, emulsions, suspensions, drops, capsules, caplets or gel caps and other methods of oral administration known to one skilled in the art. The medicament may also be administered parentally. Other routes of administration include but are not limited to: topical, transdermal, nasal, rectal, ocular, sublingual, inhalation, and vaginal. For topical and transdermal administration, the medicament may be delivered in a cream, gel, ointment, spray, suspension, emulsion, foam, or patch or by other methods known to one skilled in the art. For nasal administration, the medicament may be delivered by sprays, drops, emulsions, foams, creams, or ointments or by other methods known to one skilled in the art. For nasal administration, formulations for inhalation may be prepared as an aerosol, either a solution aerosol in which the active agent is solubilized in a carrier, such as a propellant, or a dispersion aerosol, in which the active agent is suspended or dispersed throughout a carrier and an optional solvent. For rectal administration, the medicament may be delivered using suppositories, enemas, creams, foams, gels, or ointments or by other methods known to one skilled in the art. For ocular administration, the medicament may be delivered in drops, sprays, injections, solutions, emulsions, suspensions, or ointments, or by other methods known to one skilled in the art. For sublingual administration, the medicament may be delivered in tablets, troches, liquids, emulsions, suspensions, drops, capsules, caplets or gel caps and by other methods of oral administration known to one skilled in the art. For administration by inhalation, the medicament may be delivered in vapor, mist, powder, aerosol, or nebulized form, or by other methods known to one skilled in the art. For vaginal administration, the medicament may be delivered in solutions, emulsions, suspensions, ointments, gels, foams, or vaginal rings or by other methods known to one skilled in the art.

The medicament may be in a dosage form that immediately releases the drug. In an alternative embodiment, the medicament may have a controlled release dosage form. In one embodiment, the medicament is packaged in liposomes. In a further embodiment, the liposome comprises a phospholipid. In a further embodiment, the phospholipid in the liposome is selected from phosphatidylcholine (PC), phosphatidylglycerol (PG), phosphatidylinositol (PI), phosphatidylserine (PS), phosphatidylethanolamine (PE), phosphatidic acid (PA), egg phosphatidylcholine (EPC), egg phosphatidylglycerol (EPG), egg phosphatidylinositol (EPI), egg phosphatidylserine (EPS), egg phosphatidylethanolamine (EPE), egg phosphatidic acid (EPA), soy phosphatidylcholine (SPC), soy phosphatidylglycerol (SPG), soy phosphatidylserine (SPS), soy phosphatidylinositol (SPI), soy phosphatidylethanolamine (SPE), soy phosphatidic acid (SPA), hydrogenated egg phosphatidylcholine (HEPC), hydrogenated soy phosphatidylcholine (HSPC), dipalmitoylphosphatidylcholine (DPPC), dioleoylphosphatidylcholine (DOPC), dimyristoylphosphatidylcholine (DMPC), dimyristoylphosphatidylglycerol (DMPG), dipalmitoylphosphatidylglycerol (DPPG), di stearoylphosphatidylcholine (DSPQ), di stearoylphosphatidylglycerol (DSPG), dioleoylphosphatidyl-ethanolamine (DOPE), palmitoylstearoylphosphatidyl-choline (PSPC), palmitoylstearolphosphatidylglycerol (PSPG), mono-oleoyl-phosphatidylethanolamine (MOPE), dilauroyl ethylphosphocholine (DLEP), dimyristoyl ethylphosphocholine (DMEP), dipalmitoyl ethylphosphocholine (DPEP), distearoyl ethylphosphocholine (DSEP), dimyristoylphosphatidic acid (DMPA), dipalmitoylphosphatidic acid (DPPA), distearoylphosphatidic acid (DSPA), dimyristoylphosphatidylinositol (DMPI), dipalmitoylphosphatidylinositol (DPPI), di stearoylphosphatidylinositol (DSPI), dimyristoylphosphatidylserine (DMPS), dipalmitoylphosphatidylserine (DPPS), distearoylphosphatidylserine (DSPS), N-acylated phosphorylethanolamine (NAPE), and combinations thereof

In a further embodiment, the controlled release formulation comprises a semi-permeable membrane. The muscarinic Activator and muscarinic Inhibitor may be in different membranes in the same formulation. In another embodiment, the muscarinic Activator and muscarinic Inhibitor can be in different membranes in different formulations or dosing vehicles. In a further embodiment, the semi-permeable membrane comprises a polymer. In a further embodiment, the controlled release formulation comprises a matrix that suspends the muscarinic Activator(s) and Inhibitor(s). The muscarinic Activator and Inhibitor may be in separate matrices within the same medicament. In a further embodiment, the matrix comprises a polymer. In a further embodiment, the polymer comprises a water soluble polymer. In a further embodiment, the water soluble polymer is selected from Eudragit RL, polyvinyl alcohol, polyvinylpyrrolidone, methyl cellulose, hydroxypropyl cellulose, hydroxypropylmethyl cellulose, polyethylene glycol, and mixtures thereof. In a further embodiment, the polymer comprises a water insoluble polymer. In a further embodiment, the water insoluble polymer is selected from Eudragit RS, ethylcellulose, cellulose acetate, cellulose propionate, cellulose acetate propionate, cellulose acetate butyrate, cellulose acetate phthalate, cellulose triacetate, poly(methyl methacrylate), poly(ethyl methacrylate), poly(butyl methacrylate), poly(isobutyl methacrylate), poly(hexyl methacrylate), poly(isodecyl methacrylate), poly(lauryl methacrylate), poly(phenyl methacrylate), poly(methyl acrylate), poly(isopropyl acrylate), poly(isobutyl acrylate), poly(octadecyl acrylate), poly(ethylene), poly(ethylene) low density, poly(ethylene) high density, poly(propylene), poly(ethylene terephthalate), poly(vinyl isobutyl ether), poly(vinyl acetate), poly(vinyl chloride), polyurethane, and a mixtures thereof In a further embodiment, the matrix comprises a fatty compound. In a further embodiment, the fatty compound is a wax or glyceryl tristearate. In a further embodiment, the polymer comprises a water soluble polymer and a water insoluble polymer. In a further embodiment, the matrix further comprises a fatty compound.

The medicament may be in dosage forms that use other methods of controlled release formulation known to one in the art (for example, Dixit & Puthli. J. Control Release. 2:94. 2009; Mizrahi & Domb. Recent Pat Drug Deliv Formul. 2:108. 2008; Forqueri & Singh. Recent Pat Drug Deliv Formul. 3:40. 2009; Kalantzi et al. Recent Pat Drug Deliv Formul. 3:49. 2009; Iconomopoulou et al. Recent Pat Drug Deliv Formul. 2:94. 2008; Panos et al. Curr Drug Discov Technol. 5: 333. 2008;. Wan et al. Nanomed. 2:483. 2007. Wang et al. Drug Delivery: Principles & Applications. Wiley 2005).

In another embodiment, the medicament is used in combination with one or more therapies that can include both psychotherapy and drugs. Therapeutic agents include but are not limited to antipsychotics, anxiolytics, anti-depressants, sedatives, tranquilizers and other pharmacological interventions known to one skilled in the art. A therapeutic agent may fall under the category of more than one type of drug. For instance benzodiazepines can be considered anxiolytics, sedatives and tranquilizers.

The above-described benefits of the novel methods and compositions of the present invention are illustrated by the non-limiting examples that follow.

EXAMPLES Example 1

In one example, the invention is a single capsule formulation containing 75 milligrams of xanomeline and 20 milligrams of trospium chloride. The capsule consists of a gelatin shell surrounding a fill material composed of the active compounds, a vehicle, a surfactant and a modifier. The vehicle is polyethylene glycol with a molecular weight in the range of from 500 to 10,000 Daltons and is 10% of the fill material by weight. The surfactant is polysorbate 80 and represents 0.1% by weight of the fill material. The modifier is fumed silica present at 0.25% by weight of the fill material. The total fill material represents 50% of the total capsule weight and the gelatin shell is 50% of the total capsule weight.

Example 2

A second formulation is the capsule in Example 1 with an additional outer controlled release layer comprising an enteric material (material that is relatively insoluble in the acidic environment of the stomach). There are a variety of enteric materials known to one skilled in the art. For this specific formulation we use hydroxyethylcellulose which would compose 20% of total capsule weight.

Example 3

A third example is a formulation prepared as in Example 2, with the capsule containing 225 mg of xanomeline and 60 milligrams of trospium chloride.

Example 4

In one example, the invention is a single capsule formulation containing 75 milligrams of xanomeline and 5 milligrams of solifenacin. The capsule consists of a gelatin shell surrounding a fill material composed of the active compounds, a vehicle, a surfactant and a modifier. The vehicle is polyethylene glycol with a molecular weight in the range of from 500 to 10,000 Daltons and is 10% of the fill material by weight. The surfactant is polysorbate 80 and represents 0.1% by weight of the fill material. The modifier is fumed silica present at 0.25% by weight of the fill material. The total fill material represents 50% of the total capsule weight and the gelatin shell is 50% of the total capsule weight.

Example 5

A second formulation is the capsule in Example 4 with an additional outer controlled release layer comprising an enteric material (material that is relatively insoluble in the acidic environment of the stomach). There are a variety of enteric materials known to one skilled in the art. For this specific formulation we use hydroxyethylcellulose which would compose 20% of total capsule weight.

Example 6

A third example is a formulation prepared as in Example 52, with the capsule containing 225 mg of xanomeline and 10 milligrams of solifenacin.

Example 7

Clinical Study to Evaluate the Ability of Trospium Chloride to Reduce Adverse Events Associated with Xanomeline and to Evaluate the Overall Tolerability of the Combination of Xanomeline and Trospium Chloride

We conducted a Phase I, double-blind, randomized multiple-dose pilot study of xanomeline administered alone compared to xanomeline administered in combination with trospium chloride in normal healthy volunteers. The primary objectives of this study were (1) to assess the safety and tolerability of administering, for 7 days, 225 mg daily of xanomeline with 40 mg daily of trospium chloride, versus administering 225 mg daily of xanomeline alone for 7 days; and (2) to determine whether the addition of trospium 40 mg daily (20 mg BID) to xanomeline 225 mg daily (75 mg TID) over 7 days significantly reduces peripheral cholinergic side effects (nausea, diarrhea, vomiting, sweating, excess salivation) versus xanomeline 225 mg daily, alone. The parameters of the study were as follows:

Sample Size: N = 70 subjects Study Population: Normal healthy volunteers; ages 18-60 Study Duration: Treatment: Nine days; a two-day run-in period of either placebo or trospium 40 mg/day, followed by 7 days of active treatment Follow-up: 14 days following discharge from clinic Test product, Xanomeline, 75 mg capsules, TID, for a 225 mg total daily dose dose and mode of Trospium chloride, 20 mg tablet, over-encapsulated, for a 40 mg administration: total daily dose, BID Matching placebo Study Design The study was an inpatient study conducted in normal healthy (see also FIG. 2) volunteers. Between study days −21 to −7, normal healthy volunteers visited the clinic to receive and sign Informed Consent and undergo screening procedures. Patients entered the clinic on Study Day 0 for baseline safety assessment and enrollment in the study. On the morning of Study Day 1 subjects began administration of study drug. Subjects randomized to the xanomeline-only arm received placebo for the first two days, and began TID xanomeline treatment on Day 3. Subjects randomized to the xanomeline + trospium arm received BID trospium chloride for the first two days, and then TID xanomeline plus BID trospium starting on Day 3. Matching placebo was administered to maintain the blind. Patients remained in clinic under observation for the full duration of treatment (9 days). Main criteria Age 18-60 for inclusion: Female subjects had to be postmenopausal (at least 2 years prior to dosing) or agree to use an acceptable form of birth control from screening until 14 days after completion of the study. If on birth control pills, had to have been on a stable dose for ≧12 months. Good general health Ability to give informed consent and understand verbal instructions Willingness to spend 10 days in an in-patient facility Main criteria History or presence of clinically significant cardiovascular, for exclusion: pulmonary, hepatic, renal, hematologic, gastrointestinal, endocrine, immunologic, dermatologic, neurologic, oncologic, or psychiatric disease or any other condition that, in the opinion of the investigator, would jeopardize the safety of the subject or the validity of the study results. (Subjects with any history of resolved cancer that was >5 years passed could be included.) Body Mass Index <18 or >40 kg/m² History of or high risk of urinary retention, gastric retention, or narrow-angle glaucoma History of alcohol or drug abuse within the last 24 months, or current abuse as determined by urine toxicology screen Clinically significant abnormal finding on the physical exam, medical history, ECG, or clinical laboratory results at screening Had participated in another clinical trial within 90 days prior to the first dose of study medication Needed to take any prescription medication besides the investigational product or those specifically noted above. Use of any vitamins, herbs, supplements, or over the counter medications are excluded within one week of enrollment, and during the course of the trial. Specifically, subjects were not permitted to take Benadryl ® for one week prior to and during the course of the study. Use of any tobacco products within the past 30 days Previous positive test for HIV 1 and/or 2, or Hepatitis A, B, or C, or a positive test obtained at screening. Selected Treatment emergent signs and symptoms (adverse event incidence Endpoints: rates) Cholinergic treatment emergent signs and symptoms (salivation, sweating, nausea, vomiting, diarrhea) (cholinergic adverse event incidence rates). These adverse events were observed at high rates in past xanomeline studies and were drivers of subject discontinuation.

70 total study subjects were randomized, and of these, 68 study subjects received at least one assessment on day 3, which was the first day of xanomeline administration. The demographics of the study subjects were as follows:

Xanomeline Xanomeline + alone Trospium Characteristic (N = 33) (N = 35) Age (years; Mean [SD]) 34.8 [8.8] 40.9 [12.3] Gender (M/F; [%]) 21/12 27/8  64%/36% 77%/23% Race (White/  9/24 13/21 Non-White; [%]) 27%/70% 37%/60% Weight (kg; Mean [SD]) 88 [17] 88 [16] BMI (kg/m2; Mean [SD]) 29.1 [5.0] 28.8 [5.0]

The most common adverse events with xanomeline are the so-called cholinergic adverse events of nausea, vomiting, diarrhea, excessive sweating, and excessive salivation. In this study, the co-administration of trospium chloride with xanomeline led to a statistically significant 43% reduction (p=0.016) in the incidence rate of cholinergic adverse events compared to xanomeline co-administered with placebo. In the xanomeline+placebo arm of the study, 63% of subjects reported at least one cholinergic adverse event, compared to only 34% of subjects reporting such an event in the xanomeline+trospium chloride arm of the study.

Further, in the study, each kind of individual cholinergic adverse event also had a decreased incidence rate in subjects administered xanomeline+trospium chloride, compared to the incidence rate in subjects administered xanomeline+placebo. The decrease in incidence rate of sweating was statistically significant on its own, at 20.0% in the xanomeline+trospium chloride arm, down from 48.5% in the xanomeline+placebo arm, which was a reduction of 59% (p=0.013).

In addition, the overall cholinergic adverse event rate in the xanomeline+trospium chloride arm of the study was very similar to the 32% incidence rate reported during the two day run-in period for subjects on placebo+placebo. Although these two data points are not perfectly comparable given that they occurred during different periods of the study, the fact that the cholinergic adverse event rate was comparable to that of placebo suggests that the 43% reduction in adverse events due to trospium chloride may have been close to the maximum reduction possible in this study.

The incidence and number of cholinergic adverse events in the evaluable population of the study was as follows, with all p-values based on a chi-squared test, with the exception of those marked with a * which werebased on a Fisher's exact test:

Xanomeline + Xanomeline + placebo (N = 34) Trospium (N = 35) P-value (n [%] [# (n [%] [# for % Re- Category of events]) of events]) difference duction Any 21 (63.6%) 64  12 (34.3%) 33 0.0155 46% TEAEs Nausea 8 (24.2%) 11 6 (17.1%) 8 0.4693 29% Vomiting 5 (15.2%) 5  2 (5.7%) 2   0.2522* 62% Diarrhea 7 (21.2%) 8  2 (5.7%) 4   0.0794* 73% Sweating 16 (48.5%) 24  7 (20.0%) 8 0.0131 59% Salivation 12 (36.4%) 16   9 (25.7%) 11 0.342  39%

In addition to evaluating whether the addition of trospium chloride improved the tolerability of xanomeline, the study also provided data about the overall safety and tolerability of xanomeline+trospium chloride. Overall, the combination was well tolerated with no severe adverse events and no serious adverse events, and with the vast majority of adverse events being classified as mild, as shown in the following:

Xanomeline + Xanomeline + placebo Trospium Category (n (%) # events) (N = 33) (N = 35) Subjects with any TEAE 27 ( 81.8) 108 23 (65.7) 73 Max Severity of TEAE Mild 22 (66.7) N/A 20 (57.1) N/A Moderate 5 (15.2) N/A 3 (8.6) N/A Severe 0 (0.0) 0 (0.0) Any clinically significant TEAE 5 (15.2) 5 3 (8.6) 6 Any study drug related TEAE 23 (69.7) 92 18 (51.4) 57 Max severity of study drug related TEAE Mild 19 (57/6) N/A 15 (42.9) N/A Moderate 4 (12.1) N/A 3 (8.6) N/A Severe 0 (0.0) N/A 0 (0.0) N/A Any SAE 0 (0.0) 0 0 (0.0) 0 AE leading to discontinuation (D/C) 2 (6.1) 2 1 (2.9) 1 Study drug related AE leading to D/C 1 (3.0) 1 0 (0.0) 0

The tolerability profile that we found in this study allows future studies of the combination of xanomeline and trospium chloride to proceed.

References

All publications and patents mentioned herein are hereby incorporated by reference in their entirety as if each individual publication or patent was specifically and individually incorporated by reference. In case of conflict, the present application, including any definitions herein, will control.

Equivalents

While specific embodiments of the subject invention have been discussed, the above specification is illustrative and not restrictive. Many variations of the invention will become apparent to those skilled in the art upon review of this specification. The full scope of the invention should be determined by reference to the claims, along with their full scope of equivalents, and the specification, along with such variations.

Unless otherwise indicated, all numbers expressing quantities of ingredients, reaction conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term “about.” Accordingly, unless indicated to the contrary, the numerical parameters set forth in this specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained by the present invention. 

What is claimed is:
 1. A method of treating a central nervous system disorder in a patient, the method comprising administering xanomeline and trospium chloride to the patient, the central nervous system disorder being selected from schizophrenia, Disorders Related To Schizophrenia, Muscarinic Disorder, Movement Disorder, Mood Disorder, Cognitive Disorder, Attention Disorder, and Addictive Disorder.
 2. The method of claim 1, wherein the central nervous system disorder is schizophrenia.
 3. The method of claim 1, wherein the central nervous system disorder is Alzheimer's disease.
 4. The method of claim 1, wherein the central nervous system disorder is Huntington's disease.
 5. The method of claim 1, wherein the central nervous system disorder is Parkinson's disease.
 6. The method of claim 1, wherein the central nervous system disorder is Lewy Body dementia.
 7. The method of claim 1, wherein 225 mg of xanomeline and 40 mg of trospium chloride are administered to the patient during a 24-hour period.
 8. A method of improving the tolerability of xanomeline in a patient, comprising administering to the patient xanomeline in combination with trospium chloride.
 9. The method of claim 8, wherein the xanomeline and the trospium chloride are in the same dosage vehicle.
 10. The method of claim 8, wherein the xanomeline and the trospium chloride are in different dosage vehicles.
 11. The method of claim 8, wherein 225 mg of xanomeline and 40 mg of trospium chloride are administered to the patient during a 24-hour period. 